Spotlight Case March 2007

1. Spotlight Case March 2007 Failure to Report

2. Source and Credits • This presentation is based on the March 2007 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available through the Web site • Commentary by: Patrice L. Spath, BA, RHIT, Brown-Spath & Associates • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • List common causes of medication errors • Appreciate the magnitude of underreporting of adverse events • List the common barriers to reporting adverse events and near misses • Discuss steps individuals and institutions can take to increase reporting

4. Case: Failure to Report A well-appearing 9-month-old infant weighing 8 kg presented with urinary frequency and white cells in her urine. The emergency department (ED) physician ordered Rocephin (the brand name for the antibiotic ceftriaxone) 450 mg IM for empiric treatment of a UTI to be given immediately.

5. Case: Failure to Report Several hours later, when removing another vial of ceftriaxone from the automated dispensing cabinet (Pyxis), the nurse noted there were two vials in the drawer instead of the expected one. In the medicine administration area, the nurse found a partially empty vial of cefazolin, a different antibiotic that had not been ordered for any patient that night.

6. Case: Failure to Report On the top of the vial was a chalky dried substance, and the admixture remaining in the bottle was cloudy. In this institution, ceftriaxone is routinely mixed with 1% lidocaine to decrease post-injection pain. The resulting mixture is clear and colorless. It was concluded that the infant most likely received 450 mg of IM cefazolin instead of the intended 450 mg of ceftriaxone.

7. What Went Wrong? • Similarly named medications stored in close proximity • No separation of look-alike or sound-alike meds in Pyxis • Failure of safe guards • RN failure to confirm med identity prior to administration • An environment predisposed to distractions Aspden P, et al. National Academy Press; 2007.

8. Error Prevention: Contributory Factors • Periodic pharmacy inspections of all drug storage areas • Separation of inventory will reduce mix-ups caused by look-alike/sound-alike drugs • Minimize interruptions during drug retrieval by creating a zone of safety around medication storage See Notes for references.

9. Error Prevention: Latent Factors • Ask questions • Why are sound-alike drugs stored in close proximity? • Why haven’t steps been taken to reduce cognitive overload on caregivers? • Combat complacency • Engage in dialogue about patient safety with goal of creating greater awareness of what can go wrong and greater willingness to reduce hazards Weick KE, Sutcliffe KM. John Wiley and Sons; 2001.

10. Case: Failure to Report (cont.) The nurse who had given this medication was very upset and spoke with the ED physician on duty about the event, as 450 mg of IM cefazolin is an overdose for an 8 Kg baby. She was informed that the medications were essentially equivalent. She did not pursue the matter further or report the error to her supervisor or through the institution’s incident reporting system.

11. Failure to Acknowledge Errors • “Conspiracy of silence” • Natural human impulse to hide mistakes so potential problems can be avoided • Professional attitudinal barriers • Individual feelings of helplessness, fear, and anxiety • Avoidance of guilty feelings See Notes for references.

12. Failure to Acknowledge Errors • Even when caregivers concede a mistake has been made, it often goes unreported, impeding organizational learning and often individual learning • Underreporting of adverse events estimated to range from 50% to 96% annually • Underreporting no-harm or “near miss” errors is even greater Kohn L, et al. National Academy Press; 2000.Bates DW, et al. J Gen Intern Med. 1995;10:199-205.

13. Failure to Report: Missed Opportunity • To inform parent and warn of potential toxicity and warning signs • To create a learning opportunity for staff and a chance to evaluate the system for improvements See Notes for references.

14. Missed Learning Opportunity • Individual level • Perform self-critiquing, a team activity that involves debriefing of recently completed activities to create error solutions and reduce complacency • Organizational level • Complete incident report for this event allowing learning opportunity to be expanded to entire organization See Notes for references.

15. Barriers to Reporting Adverse Events • Fear of disciplinary action • Perception that management would take no notice and was not likely to do anything about the problem • Belief that incidents are part of the job and cannot be prevented • Submitting a report is too difficult or time consuming van der Schaaf T, Kanse L. National Academic Press; 2004:119-126.

16. To Improve Reporting,Pleading is Not Enough • “It’s your professional duty.” • “The incident database will help identify improvement opportunities.” • “We can see if our safety improvement efforts are making a difference.”

17. How to Improve Reporting:Create a Culture of Safety • Caregivers must feel safe from undeserved disciplinary action or retaliation • A study of hospital nursing units found that higher reporting rates were correlated with unit members’ perception of the risk of discussing mistakes openly Edmondson AC. J Appl Behav Sci. 1996;32:5-28.

18. Strategies to Improve Incident Reporting • Promote and sustain a culture of learning from mistakes • Make incident reporting an individual performance expectation • Have clear definitions for reportable events that everyone understands • Make it easy to report and provide several different reporting methods • Allow for anonymous error reporting

19. Strategies to Improve Incident Reporting • Maintain a confidential incident reporting system • Use reports to identify common error producing factors, not to just create incident counts • Share the learning derived from incident analyses with physicians and staff • Communicate and celebrate improvements that result from analyzing reported events

20. Successful Reporting Systems • Addition of a 24-hour call center in South Central Australia • Incident reports submitted increased by 275% • Success attributed to enhanced reporting accessibility and new culture of openness • The VA incident reporting system • More than 140,000 incident reports submitted in first 5 years • Success attributed to non-punitive culture and assurance of reporter confidentiality See Notes for references.

21. Successful Reporting Systems • Neonatal intensive care incident reporting project sponsored by the Vermont Oxford Network • High rate of reporting • Success attributed to availability of a secure Internet site for anonymous event reporting • Kaiser Permanente San Diego (CA) Medical Center executive walkarounds • Leaders personally speak with physicians and staff about the importance of learning from mistakes • Success attributed to reinforcement of “just culture” and visible improvements resulting from reported incidents See Notes for references.

22. Take-Home Points • The majority of adverse events go unreported • Near misses and adverse events provide valuable teaching opportunities for caregivers and organizations • Caregivers should incorporate reporting into routine practice • Organizations should work to create a safe environment that encourages reporting and provides a streamlined, user-friendly process Aspden P, et al. National Academy Press; 2007.Medication Errors. ECRI; November 2004.