Florence Nightingale Notes on Hospitals , 1859

1. An Introduction to Patient SafetyPat Croskerry MD, PhDPatient Safety Officer CourseCPSI, Ottawa April 2011

2. ‘It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm’ Florence Nightingale Notes on Hospitals, 1859

3. The case of Sandra Geller

4. 2004

5. Sandra Geller • 68 y/o with CAD • Elective CABG - -> Sx went well • Lung infection developed on respirator • Small CVA • ARF -> short term renal dialysis • 2 weeks in ICU, ready for floor • Generalised seizure

6. Sandra Geller • Intubated without difficulty • Did not desaturate significantly • CT scan – nothing new • Remained in a coma for 2 weeks • Life support withdrawn in accordance with her wishes in living will • Died

7. The Slip in her Care • 1 hour after seizure • Nurse cleaning up bedside table • Found two medication vials • Similar size, shape, with similar labels • One was heparin, the other insulin

8. This is an example of an adverse event (AE)

9. Adverse EventAn event of commission or omission arising during clinical care causing unintended physical or psychological injury to a patient, their family or friends, and not due to the underlying disease process. It may result in prolonged hospital stay, temporary or permanent disability, or death.

10. Delayed or missed diagnoses Medication errors Wrong side surgery Wrong patient surgery Equipment failure Patient identity Transfusion errors Mislabeled specimen Patient falls Time delay errors Laboratory errors Radiology errors Procedural error Sexual or physical assault Lost, delayed, or failures to follow up reports Retention of foreign object following surgery Contamination of drugs, equipment Intravascular air embolism Failure to recognise hypoglycemia Failure to treat neonatal hyperbilirubinemia Stage lll or lV pressure ulcers acquired after admission Wrong gas delivery Deaths associated with restraints/bedrails Adverse Events

11. How do we know an AE has occurred? • Voluntary reporting • Mandatory reporting • Informal • Direct observation • Patient complaint • Medico-legal action • Medical records • Chart review

12. Determinants of Adverse Events • The People • The System

13. The System Adverse Event HFE Healthcare Workers

14. Sources of System Error • Overall culture • Education/Training • System design / HFE • Resource availability • Demand/Volume

16. Medical environments are highly variable and the safety threats and the barriers to control them vary from one to another

17. From the relative quiet of an oncology clinic…

18. Need to hurry Long waits to be seen Fatigue Phone calls Noise Uncertainty Teaching obligations Many sick patients Full bladder Work area design Home stress Dim lighting New trainees Faulty communication Multi-tasking Multi-tasking Violence Hunger Ambiguity Shift work Short-staffed Constant interruptions Technology won’t work Lack of resources Availability of consultants Faulty or missing processes Angry patients

19. How long have we been aware of adverse events?

20. 120 60 0 1939 1970 1998 Year

21. MILESTONES • 1991 Harvard Medical Practice Study • Quality in Australian Health Care Study • 1996 Annenberg conferences • 1999 Colorado / Utah Study • 1999 IOM Report: To Err is Human • 2000 BMA/BMJ London Conference on Medical Error • SAEM: San Francisco Conference on EM Error • 2000 NHS report: An Organization with a Memory • ____________________________________________________ • 1st Halifax Symposium on Medical Error • 2001 RCPSC National Steering Committee on Patient Safety • 2002 RCPSC Report: Building a Safer System • Canadian Institute of Patient Safety • 2004 Baker-Norton Report on Canadian Adverse events • 2002–9 Halifax Series of Symposia on Patient Safety

23. 10%On average, about one in ten hospitalised patients suffer an adverse event

24. 50%On average, about half of all adverse events are considered preventable

25. Anesthesia as the Principal Cause of Death 1948 (U.K.) Macintosh: ‘all anesthetic deaths are preventable’ • 1955-59 (U.S. Phillips) ~ 6% • 1961 (U.S) ~0.12 • 1982 (U.K.) ~ 0.01 • Current ~ 0.0005 (5 per million)

26. Comparison of Risk in Health Care With Other Industries

27. The extent of the problem in the US • 100,000 deaths annually due to medical errors (7 th leading cause of death) • Revised estimate (2004) put rate at 195,000 • Motor vehicle accidents - 43,000 • Breast cancer - 42,000 • AIDS - 17,000 • Error cost in mid-1990s: $29 billion annually Error problem

28. The Canadian Adverse Events Study: the incidence of adverse events in hospital patients in Canada Baker, Norton et al., CMAJ 2004

29. Canadian Adverse Events Study (CAES) • In the year 2000 • 20 acute care hospitals • 5 provinces (BC, Alberta, Ontario, Quebec, NS) • 3,745 adult patient charts • Medical and surgical admissions • No pediatric, obstetric or psychiatric cases

30. CAES • Adverse event rate 8% Extrapolates to 185,000 annually • Preventable adverse events ~ 37% Extrapolated preventable AEs annually ~ 70,000 • 5% AEs had permanent disability Extrapolates to 3422 preventable annually • Death rate from preventable AEs was 0.66% with 95% confidence interval of (0.37-0.95) • Extrapolates to preventable deaths in range 9000-24,000 annually

31. CAES • Patients with an AE spent additional 6 days in hospital • Average cost ~ $5000 • Total preventable AEs annually ~70,000 • Potential cost saving >$300 million

32. Why has it taken until now to find this out?

33. Striving for Perfection ‘Among the powerful barriers to making progress in patient safety is an attitude of complacency induced by the rarity of serious events and the general human bias toward assuming that things will work as they are supposed to’. Lucian Leape, 2002

35. The (historical)Culture of Silence

37. Culture of Silence • First do no Harm • Denial • Power to Heal • Peer Disapproval • Professional Censure • Legal Implications • Livelihood • Discomfort

38. Disclosing an adverse event(an example from the ED)

41. Ergonomics(Human Factors Engineering)

42. Poor ergonomic design in healthcare • Space organization • Information Technology • Hand-wash stations • Lighting • Monitors • Infusion pumps

43. Poor Ergonomics • Inconvenience worker and may make workplace unsafe • In healthcare setting may also make patient unsafe

44. WHY NOT DISCLOSE ERROR ? • Error is trivial • Most errors do not cause harm • Patient is ignorant about the concept of error • May impair the patient’s trust in the system • May force search for alternatives

45. Change began about 15 years ago

46. Culture of Silence to a Culture of Safety

47. Two Major Errors in Sandra’s Case • Medication error • Cognitive error

48. The Medication Process Prescription Transcription Dispensing Administration Monitoring

49. Medication process • Up tp 50 steps between a doctor’s decision to order a medication for a hospitalized patient and the actual delivery of the medication to the patient • Even if all 50 go right 99% of the time, the chances of an error are about 40%

50. Prescription MEDICATION ERRORS Transcription Dispensing Misconnection Connection Errors Administration Disconnection Monitoring