Medical Error

1. Medical Error Jeff Plant MD FRCPC June 27, 2002

2. Outline • Importance of the issue • Why are we prone? • Personal error • Systemic error • Dealing with error • Where to go from here?

4. Medical Error • Missed Salter 3 fracture • Sent home in post. slab as ?salter 1 # • Missed pyloric stenosis • Sent home with anti-reflux measures • Missed volvulus • Sent home as viral URTI

5. And so, the process begins…

6. What is Error? • Error - the failure of a planned action to be completed as intended or the use of a wrong plan to achieve a goal • Active error (sharp end) • Occur at the level of the front-end and their effects are felt almost immediately • Latent error (blunt end) • Removed from the direct control of the operator

7. Why is this important? • To Err is Human:Building a Safer Health Care System • “…when agreement has been reached to pursue a course of medical treatment, patients should have the assurance that it will proceed correctly and safely so they have the best chance possible of achieving the desired outcome.”

8. Why is this important? • Estimated that between 1-4% of hospitalizations effected by error • 5-20% of errors led to death • Eighth leading cause of death in US (more than MVC’s or AIDS)

9. Why is this important? • Estimated that 40-60% of all diagnoses wrong • Effect on physician… • Effect on patient/society…

10. What do patients expect? • Witman et al, 1996 Arch Int Med • They want admission and, if necessary, apology for error • Half as likely to proceed with litigation if error admitted by physician

11. Why are we prone? • Medical culture • Usually no mass casualties • Socialized to view error as negligence • Responsible for everything that happens to your patient • No admission of error • The People’s Court…

12. Why are we prone? • Emergency medicine • Living in a fishbowl • Held to high standards • Complex and tightly coupled system • Time sensitive • Multiple tasks ongoing

13. Medical Error - Personal • Four steps of decision making • Data gathering • Integration and processing of information • Confirmation of diagnosis • treatment

14. Data gathering • New patient each encounter • Compressed time • Too focused • Inaccuracies of physical exam • Difficult setting

15. Integration and processing • Voytovich et al • Lack of knowledge • Premature closure • Inadequate synthesis • Omission • Premature closure highly prevalent and independent of level of training

16. Integration and processing • Errors in cognition • Slips occur with errors in automatic tasks • Mistakes occur with errors in knowledge-based function • Physiologic and psychologic factors make these more likely

17. Confirmation of diagnosis • Historical bias • Inherent strengths/weakness of test • Availability of test • Cost of test

18. Treatment • Medication errors • Technical errors • Pharmaceutical company interests • EBM = economic based medicine

19. Medical Error - System • Emergency departments are complex and tightly coupled systems • Complex • multiple interactions with other systems • multiple feedback loops • information often received indirectly

20. Medical Error - System • Tightly coupled • Many time dependent processes arranged in sequences • No tolerance for delays in processes • Sequences fixed

21. Medical Error - System • Conditions that create error (DEPOSE) • Design • Equipment • Procedures • Operators • Supplies • Environment

22. How do we cope? • Most common coping mechanisms: • Denial of responsibility (blame the system) • Discounting size of effect • Emotional distancing • Less than half discuss errors with patients • 1/3-1/2 discuss errors with colleagues

23. How should we cope? • Accept responsibility for error • Discuss with colleagues • Disclose and apologize to patients • Conduct an error analysis • Make changes to reduce further errors • Change medical culture locally and nationally in dealing with error

24. New Look • Systems rather than people • Nonpunitive approach • Emphasize multifactorial aspect • Errors will occur • Caregiver interactions • Sharp and blunt end

25. Systems rather than people • All errors are, in the end, a reflection of the system • Analysis of all components DEPOSE

26. Nonpunitive approach • View errors as opportunity to improve the system • Training vs. punishment • Encourage self-reporting to colleague/committee

27. Emphasize multifactorial aspect • Emergency dept is complex • Errors rarely occur in isolation

28. Errors will occur • Design systems with this in mind • Develop buffers • Ritualize behavior

29. Caregiver interactions • Improve communication • Formal signovers • Computer documentation of patient status and primary caregiver • Clear expectations and roles of each caregiver

30. Sharp and blunt end • Focusing on front-line is most visible • Blunt end tends to harbor latent errors • Blunt end decisions drive sharp end

31. The Teams Approach • MedTeams project • extrapolation of aviation experience • Identification of core team responsible for patient • 5 step approach

33. Teamwork approach • Everyone’s opinion respected -allowing for each individual’s expertise • Builds in certain degree of redundancy

34. Teamwork • Each team responsible for specific area • Color-coded • http://team.drc.com • Report cost savings of $3-10 per patient

35. Conclusions • Medical errors occur at a very high rate • There are both personal and system aspects of medical error • Important to acknowledge error • Go through intellectual exercise of determining why error occurred • See error as chance to improve system

36. Questions?