Patient Safety 101

1. Patient Safety 101 North American Spine Society

2. Patient Safety • Basic tenet since Hippocrates’ “first do harm” • Modern medical advances provide sophisticated, effective treatments • Also are complex, multifaceted with potential for errors in judgment, technical misadventure & system failure North American Spine Society

3. Types of Errors • Medication (harmless-harmful-lethal) • Wrong-site/procedure/patient surgery • Miscommunication • Transfusion events • MRI safety • Ineffective clinical alarms North American Spine Society

4. To Err is Human-Much publicized Institute of Medicine Report-1999 “At least 44,000” and possibly “as high as 98,000” die in US annually due to “medical errors” 8th leading cause of death in US Perspective: Car accidents 43,458 Breast Cancer 42,297 AIDS 16,516 How It Started: IOM Report North American Spine Society

5. Criticisms of the Report • Origin of numbers-National figures for deaths extrapolated from only 2 studies • Retrospective nature of reviews • Suggestion that deaths due to medical errors were exaggerated North American Spine Society

6. Impact of the Report • Major media splash • Cries of shock & horror from the public, Capitol Hill • Led to call for reporting systems • AHRQ budget increased by $20 million North American Spine Society

7. Impact Focused national attention on patient safety and heightened awareness of public, health care providers, professional societies, hospitals, government. North American Spine Society

8. Valid Issues of IOM • We know medical errors do occur • Example-wrong-site surgery. Since 1995, 232 incidents reported to JCAHO. Probably underreported. • Highlighted issues of reporting, analysis and error reduction. North American Spine Society

9. Pilot Co-pilot Crew resource management Doctor Allied health Medical teams Parallels to Aviation Safety Standardization Accident Investigation Confidential Incident Reporting North American Spine Society

10. Medical Error Reporting IOM recommended mandatory reporting Fear of litigation a significant impediment to meaningful reporting North American Spine Society

11. NASS Position NASS believes nonpunitive, confidential reporting is an important preventive measure. The goal of nonpunitive, confidential reporting is to identify errors, including near misses for correction & prevention— NOT PUNISHMENT OR LIABILITY North American Spine Society

12. Six Sigma QualityBorrowing from Industry • Coined by Motorola to set tolerance limits in manufacturing • Six sigma quality=error limit set 6 standard deviations above the mean on a normal distribution curve. • High quality standard = >3.4 defects per million opportunities.  sigma= more defects.  sigma fewer defects. North American Spine Society

13. Airline Operation 5 sigma for fatalities=230 deaths per million opportunities 4 sigma for baggage handling= 6,210 lost bags per million opportunities Health Care Anesthesia death rate between 25-50 per million opportunities in ’70s & ’80s After clinical guideline adoption, rate is 5.4 deaths per million opportunities. Close to 6 sigma quality. Six Sigma Examples North American Spine Society

14. Medical Errors as Systems Problems Concept: System failures—not individual human failures– are to blame. Systems can be designed to back up human error (the sometimes imperfect human memory). North American Spine Society

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16. Name, Shame & Blame Naming the error, shaming & blaming individuals has not reduced errors. Key to improvement is a learning health care system of 8 components. North American Spine Society

17. Informatics for information Guidelines as learning tools Learning from opinion leaders Learning from the patients Decision support systems Team learning Learning organizations Just in time and point of delivery care Learning Health Care System North American Spine Society

18. What to Do? IOM Recommendation Professional societies should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement and promoting a culture of safety… North American Spine Society

19. What Your Organization Can Do • Patient Education • Medical Professional Education (journal articles, publications, CME) • Research adverse events & their causes in your specialty • Make patient safety a research funding and advocacy priority • Join with related organizations in safety efforts North American Spine Society

20. For more information, contact: North American Spine Society (815) 675-0021 www.spine.org North American Spine Society