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Enhancing Patient Safety Through Prevention of Medical Errors

Learn about the impact of medical errors, root cause analysis, and how laboratory professionals can prevent errors. Discover common errors, IOM recommendations, and the importance of safe, effective, patient-centered, timely, efficient, and equitable care.

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Enhancing Patient Safety Through Prevention of Medical Errors

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  1. Prevention of Medical ErrorsKyle B Riding, PhD, MLS(ASCP)CMAssistant Professor of MedicineUniversity of Central Florida

  2. Objectives: 1. State the impact medical errors have on patient health and financial outcomes 2. Describe the rationale and process of root cause analysis along with the six aims of patient safety as proposed by the IOM 3. Explain how laboratory professionals can be involved in preventing medical errors

  3. Ice Breaker Activity • Break into groups of 3-5 people • Pick a member to be the scribe • Spend the given time discussing the most common errors you see in your facility • The scribe should write each of these down on their own post card • Save the post cards….we will come back to those in a little bit!

  4. Why do we need to care about Medical Error Prevention? • A 2017 survey found that 21% of Americans personally experience a medical error (IHI/NORC) • Data place medical errors as the third leading cause of premature death in the United States • Estimated 250,000-400,000 premature deaths • Direct costs are estimated at about $20 billion/year • Apply ten quality adjusted life years for each premature death and this becomes $180-200 billion/year • This represents ~40% of annual Medicare expenditures

  5. Defining Medical Errors • Grober and Bohnen (2005) defined medical errors as: “An act of omission or commission in planning or execution that contributes or could contribute to an unintended result.”

  6. Defining Medical Errors • Grober and Bohnen’s definition is derived from comparing two views on what defines error: • Outcome-driven viewpoint on error • Focus is on adverse outcomes • Historically preferred in medical community • Process-driven viewpoint on error • Focus is on process errors that could lead to adverse outcomes • Generally, we look at process versus strictly outcomes now

  7. Swiss Cheese Model This Photoby Unknown Author is licensed under CC BY-SA-NC Originally conceptualized by Dr. James Reason and demonstrates how process failures can lead to adverse outcomes for patients

  8. Lippi, Bowen, & Adcock (2016)

  9. Dawson, J 2013

  10. Common Medical Errors • What are common errors? • Misdiagnosis or delayed diagnosis • Medication errors/Inappropriate medication use • Healthcare associated infections • Falls while in medical care • Poor communication to the patient • Procedure performed incorrectly or without need

  11. Addressing Medical Errors • To address these medical errors the IOM recommended that care be: • Safe • Effective • Efficient • Timely • Patient-Centered • Equitable • These six recommendations have been around for the last 20 years…still an issue.

  12. Safe Care • Avoiding harm to patients from the care that is intended to help them What is a laboratory-related scenario where there can be a lack of SAFE care?

  13. Effective Care • Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit • avoiding underuse and misuse, respectively. What is a laboratory-related scenario where there can be a lack of EFFECTIVE care?

  14. Patient-Centered Care • Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. What is a laboratory-related scenario where there can be a lack of PATIENT-CENTERED care?

  15. Timely Care • Reducing waits and sometimes harmful delays for both those who receive and those who give care. What is a laboratory-related scenario where there can be a lack of TIMELY care?

  16. Efficient Care • Avoiding waste, including waste of equipment, supplies, ideas, and energy. What is a laboratory-related scenario where there can be a lack of EFFICIENT care?

  17. Equitable Care • Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. What is a laboratory-related scenario where there can be a lack of EQUITABLE care?

  18. Root Cause Analysis • When investigating medical errors, it is important to look at the bigger picture surrounding the error • To determine the ultimate cause(s) of the problem, you must analyze the following: • Equipment • Process • People • Materials • Environment • Management

  19. Bad Coffee RCA Example https://commons.wikimedia.org/wiki/File:Fishbone_BadCoffeeExample.jpg

  20. CIA Model • Issues we can: • Control • Influence • Accept • Examples: • Control: Mislabeled/Unlabeled & Hemolyzed Samples • Influence: Over or under utilization, IT Issues • Accept: Delayed TAT (?instrument, ?patient)

  21. Elephants in the room Control Influence Accept

  22. Thank you!Kyle.Riding@ucf.edu

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