Error in Medicine

1. Error in Medicine Joseph L. Halbach, M.D., M.P.H. Laurie Sullivan, Ph.D., CSW Department of Family Medicine New York Medical College and Saint Joseph’s Medical Center 2003 – 2004 New York Medical College Department of Family Medicine

2. Jose Eric Martinez • The tragedy and suffering of an error • A reminder that errors result from a chain of events in a system • The fallibility of physicians • The compassion that is required to continue to practice • The hope that we can do better New York Medical College Department of Family Medicine

3. Error in Medicine Today’s Agenda • The Institute of Medicine (IOM) • Epidemiology of Error • Our Role in Patient Safety New York Medical College Department of Family Medicine

4. Error in Medicine The Medical Errors/Patient Safety Movement • Hilfiker article NEJM 1984 • Mid 1990s incidents New York Medical College Department of Family Medicine

5. Error in Medicine The Medical Errors/Patient Safety Movement • The Committee on the Quality of Health Care in America (1998) New York Medical College Department of Family Medicine

6. Error in Medicine IOM Reports • To Err is Human: Building a Safer Health System • Crossing the Quality Chasm: A new Health Care system for the 21st Century • Health Professions Education: A Bridge to Quality New York Medical College Department of Family Medicine

7. Error in Medicine Institutions • Institute for Healthcare Improvement (IHI) 1991 • National Patient Safety Foundation 1996 New York Medical College Department of Family Medicine

8. Error in Medicine Institutions • Institute for Safe Medication Practices (ISMP) • Patient Safety Improvement Initiative of the Veterans Health Administration 1997 • National Quality Forum (NQF) New York Medical College Department of Family Medicine

9. Error in Medicine • Agency for Healthcare Research and Quality – (AHRQ) • July 2001 “Making Healthcare Safer: A Critical Analysis of Patient Safety Practices” • October 2001 - $50 Million grant funding including a grant to the AAFP Policy Center to study outpatient medical errors. New York Medical College Department of Family Medicine

10. Error in Medicine • The Leapfrog Group • Require hospitals to adopt computerized physician order entry. • Steer patients to hospitals/doctors with high volume of high-risk procedures. • Require ICUs to be staffed with critical care specialists. New York Medical College Department of Family Medicine

11. Error in Medicine Medical Literature Articles on Medical Error/Patient Safety in Refereed Journals by year of publication (as of 4/15/02). New York Medical College Department of Family Medicine

12. Error in Medicine To Err is Human • Establish a national focus on the issues of patient safety & medical error. New York Medical College Department of Family Medicine

13. Error in Medicine To Err is Human • Identify & learn from errors through mandatory reporting efforts & encouragement of voluntary efforts. New York Medical College Department of Family Medicine

14. Error in Medicine To Err is Human • Raise standards and expectations for improvement in safety. New York Medical College Department of Family Medicine

15. Error in Medicine To Err is Human • Create safety systems inside health care organizations through the implementation of safe practices at the delivery level. New York Medical College Department of Family Medicine

16. Error in Medicine IOM Definition of Error The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. New York Medical College Department of Family Medicine

17. Error in Medicine An Adverse Event An injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to error is a “preventable adverse event.” New York Medical College Department of Family Medicine

18. Error in Medicine Wu’s Definition A Medical Error is “…a commission or omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences.” (Wu, 1997) New York Medical College Department of Family Medicine

19. Error in Medicine Why Errors Occur “The more complex the behavior, the less likely that it can be repeated successfully.” New York Medical College Department of Family Medicine

20. Error in Medicine Why Errors Occur • Lack of Standardization • Failure to design with error in mind • A medical culture that resists admitting to error and so cannot work to prevent error. (Schenkel S. 2000 Promoting safety and preventing medical error in emergency departments. AcademicEmergencyMedicine, Nov 7: 11, 1204-1222). New York Medical College Department of Family Medicine

21. Error in Medicine Common Causes of Errors Ignorance Inexperience Faulty judgment Hesitation Fatigue Job overload Breaks in concentration System flaws (Wu AW, McPhee SJ, and Christensen JF. Mistakes in Medical Practice, Chapter 32 in Behavioral Medicine in Primary Care. 1997 Appleton and Lange, Stamford CT. Edited by MD Feldman and JF Christensen). New York Medical College Department of Family Medicine

22. Error in Medicine Who Makes Errors “The reality is that most errors are made by good people with good training, skills, and intentions who inadvertently commit errors despite their best efforts because of an unfortunate confluence of individual, workplace, communication, technologic, psychological, and organizational factors.” (Annals of Emergency Medicine, July 2000, 59) New York Medical College Department of Family Medicine

23. Error in Medicine About the Numbers In-Patient Out-Patient New York Medical College Department of Family Medicine

24. Error in Medicine The Numbers 50:1 Ratio Bates DW, O’Neil AC, Boyle D, et al. Potential identifiability and preventability of adverse events using information systems. J Am Med Inform Assoc. 1994; 1:404-411. Jha AK, Kuperman GJ, Teich JM, et al., Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J. Am Med Inform Assoc. 1998; 5;305-314. Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement . Jt Comm J Qual Improv. 1995; 21:541-548. New York Medical College Department of Family Medicine

25. Error in Medicine The Numbers 44,000-98,000 Americans die in hospitals each year as the result of medical errors. (To Err is Human, p. 44) New York Medical College Department of Family Medicine

26. Error in Medicine The Studies • (1984) New York State hospital admissions/chart review • (1994) Colorado and Utah New York Medical College Department of Family Medicine

27. Error in Medicine Worker Safety • 6,000 Americans die from workplace injuries every year • 1993, medication errors alone are estimated to have accounted for 7,000 deaths (To Err is Human, p. 44) New York Medical College Department of Family Medicine

28. Error in Medicine Preventable Adverse Events • 8th leading cause of death • motor vehicle accidents (43, 458) • breast cancer (42,297) • AIDS (16, 516) New York Medical College Department of Family Medicine

29. Error in Medicine Costs • Estimated at between $37.6 & $50 billion for adverse events • $17-29 billion for PREVENTABLE adverse events New York Medical College Department of Family Medicine

30. Error in Medicine Our Role in Patient Safety What can you do to increase patient safety in your practice? New York Medical College Department of Family Medicine

31. Error in Medicine Prevention • Openly acknowledge error in Medicine • Analysis of systems rather than individuals Vincent C. Risk, safety, and the dark side of quality. 1997: 314:1775-1776. New York Medical College Department of Family Medicine

32. Error in Medicine Specific Suggestions • Plan a response to your next error. • Become familiar with your institution’s policies. • Recognize your role as an Educator. New York Medical College Department of Family Medicine

33. Error in Medicine What Patients Want • What happened? • That we are sorry • How are we going to prevent error in the future? New York Medical College Department of Family Medicine

34. Error in Medicine Responding to Unanticipated Outcomes • CARE: Take Care of the Patient • PRESERVE: Preserve the Evidence • DOCUMENT: Document in the Medical Record New York Medical College Department of Family Medicine

35. Error in Medicine Responding to Unanticipated Outcomes • REPORT: Complete Mandatory Reports if Required • NOTIFY: Notify Claims Department of Your Malpractice Carrier • DISCLOSE:The Initial Disclosure Discussion New York Medical College Department of Family Medicine

36. Error in Medicine Responding to Unanticipated Outcomes • ANALYZE: Analyze Unanticipated Outcome to Prevent Recurrence and /or Improve Outcome (Root Cause Analysis) New York Medical College Department of Family Medicine

37. Error in Medicine Responding to Unanticipated Outcomes • FOLLOW THROUGH: Subsequent Disclosure Discussions • HEAL: Heal the Health Care Team (Norcal Risk Management) New York Medical College Department of Family Medicine

38. Error in Medicine As an Educator • Recognize you are a role model. • Medical students and residents see errors made, make errors, do not see them discussed, and are greatly affected by medical errors. New York Medical College Department of Family Medicine

39. Error in Medicine JCAHO National Patient Safety Goals 2003 and 2004 • Improve Patient Identification • Improve communication among caregivers • Improve Safety of high-alert medications • Eliminate wrong-site, wrong-patient, wrong-procedure surgery • Improve safety of Infusion Pumps • Improve clinical alarm systems • Reduce Healthcare – acquired infections New York Medical College Department of Family Medicine

40. Error in Medicine The “New Look” “The term…is being applied to a growing body of research on human and system performance aimed at learning how complex systems fail and how people contribute to safety.” From: Phillips DF JAMA 1999; 281: 217 New York Medical College Department of Family Medicine

41. Error in Medicine The “New Look” • Emphasis on systems rather than people • Nonpunitive approach • Emphasis on the multifactorial nature of error • Assumption that errors will occur • Emphasis on caregiver interactions • Sharp end, blunt end From Wears RL and Leap LL Ann Emerg Med 1999; 34: 370-372 New York Medical College Department of Family Medicine

42. Error in Medicine “The paradox of modern quality improvement is that only by admitting and forgiving error can its rate be minimized.” • (D. Blumenthal, Editorial: Making medical errors into treasures. JAMA, 1994; 272:1867-8.) New York Medical College Department of Family Medicine