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BIDMC Philosophy and Approach to Error

Learn about BIDMC's philosophy on common errors in health care and their approach to reducing risks through systems improvement, error management, and support for those affected.

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BIDMC Philosophy and Approach to Error

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  1. BIDMC Philosophy and Approach to Error

  2. BIDMC Philosophy: • Errors are common; Health Care is Hazardous.

  3. Why are Errors Common in Health Care? • Care involves multiple steps

  4. Identification of Patients at BIDMC Example: ED to Floor RN Reg Staff Transport RN RN Lab RN Radiology MD Pt Access Transport/Lab/ Radiology , etc… … MD RN MD RN Reg Staff

  5. Chance of completing a multi-step process without an error. Error Rate No. steps 1:100 1:1000 1:10,000 1 .99 .999 .9999 10 .90 .99 .999 20 .82 .98 .998 100 .36 .90 .99 100 .00004 .31 .89 10,000 - .000009 .26 20,000 - - .07

  6. Why are Errors Common in Health Care? • Care involves multiple steps • Those steps involve Humans

  7. Read this next slide . . .

  8. Paris in the the Sring

  9. Why Do Humans Fail? • Fatigue • Environmental Conditions • Task Design • Psychological conditions • Competing Demands

  10. Why are Errors Common in Health Care? • Care involves multiple steps • Those steps involve Humans • Humans commonly make errors, especially under stress, or when information does not fit the expected pattern.

  11. Nominal Human Error Rates for Selected Activities

  12. BIDMC Philosophy: • Errors are common; Health Care is Hazardous. • We need to reduce the risk of error, predominantly by improving systems. • Accepting that errors cannot be eliminated, we need to • Learn from them • Manage the repercussions to the patient, caregivers, and any other affected groups.

  13. Intent, Vigilance & Hard Work: 10-1 Performance • Common equipment • Standard orders sheets • Personal check lists • Feedback of information on compliance • Awareness and training

  14. Learning From Error • Encourage reporting • Nonpunitive reporting policy • Easy Interface for reporting • RL Solutions Software • Department of Risk Management, staffed with 5 Patient Safety Coordinators • Review and learn from that which has been reported • Morbidity/Mortality • QI Directors • Patient Care Assessment Committee of the Board

  15. Managing those Affected by Error • Full Disclosure to patients, as information develops • Support for clinicians • In performing disclosure • In dealing with their own reaction to error.

  16. Our Goal: Learn about small problems before they become adverse events: Develop a system by which everyone in the organization consistently identifies barriers to work and care and implements solutions as close to real time as possible. Share learnings in a way that maximizes opportunity to improve quality and safety.

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