Reducing medical error and increasing patient safety

1. Reducing medical error and increasing patient safety Richard Smith Editor, BMJ

2. What I want to talk about • A story • How common is error? • Why does error happen? • How should we think of error? • How should we respond?

3. A story

4. How common is error? • Harvard Medical Practice Study • Reviewed medical charts of 30 121 patients admitted to 51 acute care hospitals in New York state in 1984 • In 3.7% an adverse event led to prolonged admission or produced disability at the time of discharge • 69% of injuries were caused by errors

5. How common is medical error? • Australian study • Investigators reviewed the medical records of 14 179 admissions to 28 hospitals in New South Wales and South Australia in 1995. • An adverse event occurred in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9% • 51% of adverse events were considered to have been preventable.

6. How common is medical error? • The differences between the US and Australian results may reflect different methods or different rates • Other, smaller studies (including one from Britain) show similar orders of errors • There are few studies from outpatients or primary care

7. How common is medical error? • An evaluation of complications associated with medications among patients at 11 primary care sites in Boston. • Of 2258 patients who had had drugs prescribed, 18% reported having had a drug related complication, such as gastrointestinal symptoms, sleep disturbance, or fatigue in the previous year.

8. Results of medical error • In Australia medical error results in as many as 18 000 unnecessary deaths, and more than 50 000 patients become disabled each year. • In the United States medical error results in at least 44 000 (and perhaps as many as 98 000) unnecessary deaths each year and 1 000 000 excess injuries.

9. Types of error • About half of the adverse events occurring among inpatients resulted from surgery. • Next come • Complications from drug treatment • therapeutic mishaps • diagnostic errors were the most common non-operative events. In the Australian study cognitive errors, such as making an

10. Types of error • Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.

11. Which patients are most at risk? • Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery • Those with complex conditions • Those in the emergency room • Those looked after by inexperienced doctors • Older patients

13. How dangerous is health care? • Less than one death per 100 000 encounters • Nuclear power • European railroads • Scheduled airlines • One death in less than 100 000 but more than 1000 encounters • Driving • Chemical manufacturing • More than one death per 1000 encounters • Bungee jumping • Mountain climbing • Health care

14. Why do errors happen? • All humans make errors: indeed, “the ability to make mistakes” allows human beings to function • Most of medicine is complex and uncertain • Most errors result from “the system”--inadequate training, long hours, ampoules that look the same, lack of checks, etc • Healthcare has not tried to make itself safe

16. How to think of error? • An individual failing • Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis • It will not solve the problem--it will probably in fact make it worse because it fails to address the problem • Doctors will hide errors • May destroy many doctors inadvertently (the second victim)

17. How to think of error? • A systems failure • This is the starting point for redesigning the system and reducing error

18. How to respond? Tactics • Reduce complexity • Optimise information processing • checklists, reminders, protocols • Automate wisely • Use constraints • for instance, with needle connections • Mitigate the unwanted side effects of change • with training, for example.

19. Building a safe healthcare system (from James Reason) • Principles • Policies • Procedures • Practices

20. Building a safe healthcare system (from James Reason) • Principles • Safety is everybody’s business • Top management accepts setbacks and anticipates errors • safety issues are considered regularly at the highest level • Past events are reviewed and changes implemented

21. Building a safe healthcare system (from James Reason) • Principles • After a mishap management concentrates on fixing the system not blaming the individual • Understand that effective risk management depends on the collection, analysis, and dissemination of data • Top management is proactive in improving safety--seeks out error traps, eliminates error producing factors, brainstorms new scenarios of failure

22. Building a safe healthcare system (from James Reason) • Policies • Safety related information has direct access to the top • Risk management is not an oubliette • Meetings on safety are attended by staff from many levels and departments • Messengers are rewarded not shot • Top managers create a reporting culture and a just culture

23. Building a safe healthcare system (from James Reason) • Policies • Reporting includes qualified indemnity, confidentiality, separation of data collection from disciplinary procedures • Disciplinary systems agree the difference between acceptable and unacceptable behaviour and involve peers

24. Building a safe healthcare system (from James Reason) • Procedures • Training in the recognition and recovery of errors • Feedback on recurrent error patterns • An awareness that procedures cannot cover all circumstances; on the spot training • Protocols written with those doing the job • Procedures must be intelligible, workable, available

25. Building a safe healthcare system (from James Reason) • Procedures • Clinical supervisors train their charges in the mental as well as the technical skills necessary for safe and effective performance

26. Building a safe healthcare system (from James Reason) • Practices • Rapid, useful, and intelligible feedback on lessons learnt and actions needed • Bottom up information listened to and acted on • And when mishaps occur • Acknowledge responsibility • Apologise • Convince patients and victims that lessons learned will reduce chance of recurrence

27. James Reason’s bottom line • Fallibility is part of the human condition • We can’t change the human condition • We can change the conditions under which people work

28. Conclusions • Human beings will always make errors • Errors are common in medicine, killing tens of thousands • We begin to know something about the epidemiology of error, but we need to know much more • Naming, blaming and shaming have no remedial value

29. Conclusions • We need to design health care systems that put safety first (First, do no harm) • We know a lot about how to do that • It’s a long, never ending job