Marwan GHOSN,MD, MBA/MHM

1. Patient’s Safety: Could It Truly Be This Awful? Marwan GHOSN,MD, MBA/MHM

2. Objectives • Sensitize the audience on the dimension of the problem • Define the medication error and its impact on Patient Safety and Healthcare System • Emphasize on the role of nurses on Patient Safety • Quality and Patient Safety • Hospital Accreditation

3. Six Key Aims of Health CareSafety Comes First ! • Safe – avoid injuries to patients • Effective – based on science • Patient centered – respectful, responsive • Timely – reduces wasteful delays • Efficient – avoid waits • Equitable – across gender, race, location, • and ability to pay

4. Medication Errorsin numbers 27 October 2014 4 When Mistakes are not an Option

5. > 1,000,000Serious Medication Errors per year in USA... Ref: Wall Street Journal/Institute of Medicine 27 October 2014 5 When Mistakes are not an Option

6. 195,000hospital deaths per year in the U.S.as a result of healthcare error2000-2002 Source: Boston Globe – 27.July.2004 HealthGrades / Denver

7. 44,000 preventable deathsoccur each year Source: Boston Globe – 27.July.2004 HealthGrades / Denver

8. “When I climb Mount Rainier I face less risk of death than I’ face on the operating table.” Donald Berwick*, “Six Keys to Safer Hospitals: A Set of Simple Precautions Could Prevent 100,000 Needless Deaths Every Year,” Newsweek (12.12.2005) *Donald Berwick is the President & CEO of the Institute of Healthcare Improvement (IHI)

9. Tommy Thompson, Secretary of the United States Department of Health & human Services (2001-2005):"Some grocery stores have better technology than our hospitals and clinics.” Source: Special Report on technology in healthcare, U.S. News & World Report (07.04)

10. Do these numbers give you a pause when you will decide to go to the hospital ? 10

11. What is “Medical Error”? 11

12. Definition of a Medication Error Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. 12

13. Medication Error include Delayed diagnoses Mistakes during treatment Medication mistakes Delayed reporting of results Miscommunications during transfers and transitions in care Inadequate post-procedure care Mistaken identity 13

14. Medication Error include Error of commission: Act of doing something incorrectly Under normal circumstances that don’t include stress & time pressures: 3 times out of 1000 Errors of omission: Something that should be done are not done In the absence of reminders: 1 time in 100 14

15. Examples • Transdermal patches • Appliance of the new patch directly on top of the old one. • Not removal of the protective linear • Not removal of the old patch when the new patch is applied. • Difficult to find “clear” patches on the skin • Accidental and intentional ingestion

16. Medication Error-prevention Strategies • Educational and competency requirements for practitioners • Organized and up-to-date patient medical record and medication profile • Coordinated care among practitioners. • Standardized medication ordering system: • Preprinted medication order forms • Computerized prescriber order entry system • Standardized format for medical order content including: dosage calculations, vocabulary and nomenclature, abbreviations, dosage limits and routes of administration.

17. Medication Error-prevention Strategies • Standardized protocols for prescribing, preparation, dispensing, and administration of medication: • Medication-order verification system (9 checkpoint system) • Documentation such as checklists, worksheets to calculate dosages and administration rates, and treatment flow sheets • Cross-checking • Manual or electronic medication monitoring • Patient and caregiver education

18. Medication Error-prevention Strategies • Quality assurance: • Periodic auditing of practitioner proficiency • Error reporting system • Analysis and resolution of medication errors • Periodic re-evaluation of medication use system

19. What are the impacts of medical error? • Harm to the patient • Moral Imperative • Professional Imperative • Financial Imperative Let’s have a look on some concrete numbers ……

20. Medical errors result in injury cost$17 to $29 Billion each year in USA Ref: Kohn LT, Corrigan JM, Donaldson MS (eds). Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer health System. Washington, DC: National Academies Press; 1999.

21. Nosocomial bloodstream infections prolong a patient’s hospitalization by a mean of7 days =>Cost per bloodstream infection range $ 3,700 and $ 29,000 Ref: Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted, cohort study. Infection Control and Hospital Epidemiology. 1999; 20 (6): 396 – 401.

22. Preventable Adverse drug events increase in length stay of 4.6 days at a cost of $ 4,685 each Ref: Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted, cohort study. Infection Control and Hospital Epidemiology. 1999; 20 (6): 396 – 401.

23. Focusing On Nursing! 23

24. Nurse Staffing, Quality of Care & Outcomes

25. Educational levels of hospital nurses and surgical patient mortality JAMA 2003

26. Nurse Staffing and impact on clinical outcome Ref: Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987-1993.Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623. Aiken LH, Clarke SP, Sloane DM, for the International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J for Qual Health Care. 2002;14:5-13.

27. Education and work environment impact on clinical outcome • Every 10% increase in the proportion of a hospital’s staff nurse workforce with a baccalaureate degree or even higher levels of education is associated with a 5% decline in mortality. • Hospitals with better nurse work environments have fewer adverse patient outcomes than hospitals with poorer work environments.

28. Turnover rateExperience of Hackensack Hospitalin New Jersey Relates its low voluntary turnover rate of RN (6.3%) to the excellent practice environment for nurses. This translates into savings of $ 45,000 to $ 68,000 in recruitment & training expenses for each nurse. A low turnover rate is associated with a culture that supports patient safety The nursing practice environment is critical to patient safety, quality of care & nurse retention.

29. Significant progresses have been made when looking at local results under surveillance Micro Results: Significant Progress Leape & Berwick, JAMA 2005

30. But much little progresses when looking at macro results… Macro Results: Little Progress Global shift: safety improvement along time of all human activities (order of magnitude : one log every 20 years) but the relative ranking of activities does not seem to change Fatal Iatrogenic adverse events Anesthesiology ASA1 Cardiac Surgery Patient ASA 3-5 Medical risk (total) No system beyond this point Hymalaya mountaineering Chartered Flight Civil Aviation Microlight or helicopters spreading activity Railways (France) Road Safety Chemical Industry (total) Nuclear Industry Fatal risk 10-2 10-3 10-4 10-5 10-6 Very unsafe Ultra safe

31. Conclusion (1) • The environments in which nurses work are complex systems that are prone to error. • Errors in nursing care are rarely due to carelessness or incompetence. • Consequently, the culture of health care organizations, created in part by nurses, needs to be “blame free”. • A learning environment, with free flowing open communication enables nurses to identify, discuss and ultimately prevent health care errors.

32. Conclusion (2) • Patients deserve and have a right to care that minimizes the likelihood of errors and that puts their safety first. • To achieve that aim, nurses and other stakeholders in health care have significant work ahead.

33. Safety Begins with you Don’t Wait for someone else