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Patient safety

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Patient safety

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    1. Patient safety Marvin J. Bittner MD MSc FACP FIDSA FSHEA VA Medical Center Creighton University School of Medicine Omaha, Nebraska

    3. Overview of SJH order sheet

    4. Sulfa allergy on SJH orders

    5. How did the allergic patient get trimethoprim-sulfa? Physician see the order sheet? Nurse see the order sheet? Pharmacy check its records? Administering nurse see Kardex?

    6. Safety conflict Blame staff vs. improve system What if they didn’t ask: Why? Why? Character defect vs. latent error Medication error vs. adverse event Is it really patient safety? Lip service vs. safe environment Errors a subject for scientific study?

    7. Patient safety issues Impact Success: Anesthesia Error science Omaha case Steps we must take amid conflict

    8. Odd controversy over Institute of Medicine’s To err is human How many deaths per year in US from medical error? About 100,000? Only 50,000? JAMA 1994: 180,000 Leape LL. Error in medicine. JAMA 1994;272:1851Leape LL. Error in medicine. JAMA 1994;272:1851

    9. Key point: Too many patients suffer 20% of admitted medical patients suffer iatrogenic injury (20% fatal) Other study: 36% (25% serious or life threatening) 64% of cardiac arrests preventable Leape 1994Leape 1994

    10. Is 99.9% good enough? W.E. Deming: If we had to live with 99.9%, we would have: 2 unsafe plane landings per day at O’Hare 16,000 pieces of lost mail every hour 32,000 bank checks deducted from the wrong bank account every hour Quoted in Leape 1994Quoted in Leape 1994

    11. Is 99.99211% good enough?

    12. 2/16/95

    13. Patient safety: Impact Tens of thousands of deaths each year, comparable to motor vehicle crashes or HIV/AIDS Very high demand for accuracy in health care Even an isolated case can generate unfavorable headlines

    14. Anesthesiology premiums down: Why? A. Malpractice insurance companies felt sorry for anesthesiologists B. Companies in a charitable mood C. Math errors by all companies D. Anesthesia is safer Gaba Dm. Anaesthesiology as a model for patient safety in health care. BMJ 2000(Mar 16);320:785-8Gaba Dm. Anaesthesiology as a model for patient safety in health care. BMJ 2000(Mar 16);320:785-8

    15. Technological solutions Monitoring, eg CO2 exhaled Interestingly, no study powerful enough to show benefit of this in preventing rare events Engineered devices, eg can’t connect gas to the wrong tubing Airway devices, eg fiberoptic laryngoscopy for difficult intubation

    16. Standards and guidelines Initially, Harvard hospitals Similar adopted by American Society of Anesthesiologists De facto standard of care Variety of topics: EKG monitoring, capnography, pulse oximetry, office anesthesia

    17. Human factors engineering, systems approach to safety Analysis of decision making Varied methods: observation, videotapes, morbidity & mortality conferences, patient simulators

    18. VA Palo Alto Simulation Room

    19. Human factors engineering, systems approach to safety Analysis of decision making Varied methods: observation, videotapes, morbidity & mortality conferences, patient simulators “Inside out”: anesthesiologist scholars

    20. Anesthesia Patient Safety Foundation 1985 institutionalization of safety Quarterly newsletter Funds research unsuitable for traditional granting agencies Cadre of investigators and scholars Policy positions

    21. Success: Anesthesia Lessons? Multiple factors: Technology, guidelines, human factors, cultural change Area of special interest: Error science

    22. Human factors engineering, systems approach to safety Analysis of decision making Varied methods: observation, videotapes, morbidity & mortality conferences, patient simulators “Inside out”: anesthesiologist scholars Systems: latent errors, high reliability organizations

    23. Error “science”: Person approach Forgetful, inattentive, unmotivated, careless, negligent, reckless Solution: posters, procedures, discipline, litigation, retraining, naming, blaming, shaming Bad things happen to bad people: “Just World” hypothesis Reason J. Human error: Models and management. BMJ 2000(Mar 15);320:768Reason J. Human error: Models and management. BMJ 2000(Mar 15);320:768

    24. Error science: System approach Humans fallible, errors expected even in best organizations Errors as consequences (not causes), due to upstream factors Hazardous technology has defenses; after event: “How? Why defenses failed” (not who failed)

    25. “Federal health officials say they will soon allow Medicare beneficiaries to obtain information about doctors who may have made errors.”—AP Dr. Paula Stengel: Phoned her mother’s house instead of her sister’s, thinking her daughter would be there, and temporarily threw her mother into a panic. The New Yorker, Feb. 12, 2001, p. 48. Shouts & Murmurs, First, Do No Harm, by Ben GreenmanThe New Yorker, Feb. 12, 2001, p. 48. Shouts & Murmurs, First, Do No Harm, by Ben Greenman

    26. Evaluating the person approach Blame is emotionally satisfying, lets institution off the hook Discourages reporting near misses Overlooks key issues Best people make mistakes, too System defects lead to errors

    27. Swiss cheese

    28. Two types of holes Active failures: Slips, lapses, fumbles, mistakes, procedural violations Latent conditions: Due to designers, management Local conditions (time pressure) Weak defenses (design error)

    29. Aircraft carriers http://www.lakehurst.navy.mil/images/aircraft-carrier-in-motion01.JPGhttp://www.lakehurst.navy.mil/images/aircraft-carrier-in-motion01.JPG

    30. High reliability organizations Hazardous conditions, but fewer than fair share of adverse events Image vs. reality: Aviation, nuclear power plants Make system reforms, not local repairs; robust despite expected human failures

    31. Northeast Blackout 8/14/03

    32. Error science illustrated: Cross country ski trip Forgot waxes Why? Distracted (child was upset), environmental stressors (snowing) Prevent? Affordance (“reminder” sticker on skis), forcing function or constraint (wrap waxes around skis with cord)

    33. Turned down road to work, not the way to skiing Slip or habit intrusion

    35. Turned down road to work, not the way to skiing Slip or habit intrusion Common examples Writing check early in Jan. 2005 with date “1/5/04” Drug name mix-up, sound-alike & pick the most common one

    36. Skied down snowmobile trail—but it was a deer trail Had okayed snowmobiling on land So mental picture or schema using stored memories & applied rule: long, narrow track = snowmobile Rules strong but wrong Loss of vigilance exacerbates this

    37. Slips & lapses vs. mistakes Due to execution or memory failure (turn to work) Skill-based, intrusion of habit Due to failure of judgment (deer track) Fit data to the wrong schema

    38. Factors promoting errors Sleep deprivation schedule for interns: 35.9% more serious errors (N Engl J Med 2004;351:1838) Emotional states, eg boredom, frustration, fear, anxiety, anger Environment, eg noise, heat, visual stimuli, motion Leape JAMA 1994;272:1853Leape JAMA 1994;272:1853

    39. Need systematic approach to safety in the hospital Distinguish errors, adverse events Nosocomial infections Are adverse events Often are not due to definable error; may not be preventable, given current knowledge

    40. Challenges in surveillance Incident reporting: Insensitive at detecting errors, but does detect most serious adverse events Strategies: Intermittent, focused

    41. Lessons from aviation Errors inevitable, systems absorb them (buffers, automation, redundancy) Standardized procedures, checklists Pilot training & certification Safety institutionalized (FAA, NTSB) Leape JAMA 1994;272:1853 Leape JAMA 1994;272:1853

    42. System design to enhance safety Simplify tasks to cut load on short-term memory, planning, problem-solving Constraints (no concentrated KCl) Standardize procedures Acts reversible (or hard to do) Leape JAMA 1994;272:1853Leape JAMA 1994;272:1853

    43. Directions for health care Discover, understand errors Prevent: Less memory, more information access, error proofing, standardization, safety training Absorb: Drug orders example Cut psychological pressures Leape JAMA 1994;272:1853 Leape JAMA 1994;272:1853

    44. Approaches to enhance safety “Let me read your order back” Reject “culture of low expectations” Practice teamwork: race car crew

    45. Crew resource management Wall Street Journal 7/7/99Wall Street Journal 7/7/99

    46. Key messages from error science Expect human fallibility Design “shields,” which are Swiss cheese Different types of errors, with different types of remedies: Slips vs. mistakes vs. knowledge vs. violations

    47. 4 given wrong 7/15/93

    48. 7/16/93

    49. 7/16/93

    50. 7/17/93

    51. 7/18/93

    52. 7/20/93

    53. 7/21/93

    54. STATGRAM

    55. Safety Recall Notice

    56. 7/24/93 editorial

    57. 7/27/93

    58. 7/29/93

    59. 7/30/93

    60. 7/31/93

    61. 8/5/93

    62. 8/5/93

    63. 8/5/93

    64. 8/6/93

    65. 8/6/93

    66. 8/13/93

    67. 9/13/93

    68. 10/11/93

    69. 10/30/93

    70. 8/26/95

    71. What happened 1/22/92 FDA oks mivacurium 8/92 Omaha VA places its 1st order 4/17/93 Collinsville, IL patient dies; night before, got mivacurium instead of ulcer medication 5/18 Mivacurium shipped with bright name stickers

    72. What happened-2 Early 6/93 stickers mailed 6/7 Omaha VA receives stickers 7/8 Four patients get mivacurium, not metronidazole, stop breathing Two die

    73. Swiss cheese

    74. Opportunities for prevention Recognize similar package design Recognize adjacent shelving Not just a STATGRAM, but sales representatives to relabel bags Label all bags after STATGRAM Not stock in main pharmacy

    75. More opportunities for prevention Read label when pulling bag Read label when labeling bag Read manufacturer’s label when administering drug Heroine?

    76. Patient safety concepts Desire to blame Disciplinary action Lawsuits, quiet notification “First story, second story” System had latent defects—nurses followed policy correctly

    77. Pharmacy error Combination of factors Active failure: Lapse, didn’t read label of similar products Latent condition: Had 2 similar products adjacent

    78. Steps we must take amid conflict Overcome tendency to blame Fix system Do conditions promote lapses? Overwork? Bad morale? “Every defect is a treasure”; find & fix latent errors

    79. Berwick 12/03 title

    80. Berwick R knee x-ray

    81. Berwick R knee x-ray close-up

    82. RFP headline

    83. Berwick RFP

    84. Boston Globe photo

    85. Boston Globe Magazine 1/4/04

    86. Berwick 12/03 title

    87. Berwick R knee x-ray

    88. Boston Globe Magazine 1/4/04

    89. Berwick 12/03 title

    90. Internal Bleeding cover

    91. Rugged Land publishers NYC

    92. East River quote

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