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SUB TITLE HERESuzanne Graham, RN, PhD
Patient Safety Patient Safety
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Let’s Talk
Objectives
• Describe the scope of error in healthcare Describe the public and patient perception of safety in healthcare
• Describe the scope of error in the outpatient setting
• Discuss why improving safety in healthcare has been difficult
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Share Your Experience
Have you or someone you’ve known experienced a medical error?
Have you or someone you’ve known contributed to a medical error?
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Why do we care?
The IOM Report 44,000-98,000 patients die each year in hospitals
from medical error Up to 270 patients die each day in hospitals due
to error More people die each year from error than from
breast cancer, motor vehicle accidents and AIDS
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How Do We Compare? (Graph created by Lucien Leape)
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
To
tal
liv
es
lo
st
pe
r y
ea
r
REGULATEDDANGEROUS(>1/1000)
ULTRA-SAFE(<1/100K)
HealthCare
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
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Headlines & Errors
• State Faults Kaiser for Fatal Injection Ulysses Torassa, San Francisco Chronicle (November 3, 2005)
• Kaiser Hospitals Implement Safeguards: New Procedures at 2 Sites Where Fatal Mistakes Occurred Kathleen Sullivan, Chronicle Staff Writer (November 5, 2005)
• State Criticizes Kaiser Over Death Kathleen Sullivan, San Francisco Chronicle (November 10,
2005)
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Headlines & Errors
• Medical Mistake May Have Killed Man Julie Sevrens Lyons, San Jose Mercury News (November 2, 2005)
• “Terrible Error”, Then a Death David L. Beck and Julie Sevrens Lyons, San Jose Mercury News
(November 3, 2005)
• Another Death in ’05 Attributed to Hospital Error Julie Sevrens Lyons, San Jose Mercury News (November 4, 2005)
• Hospitals Blamed in More Deaths David L. Beck San Jose Mercury News (November 10, 2005)
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Safety in the Outpatient World
The focus of safety until recently on the hospital Controlled hospital environment vs. less controlled
practice environment Availability of patient records High risk vs. lower risk environment Long encounters vs. short encounters Focus of regulators/accreditation
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Top Patient Concerns-NationalWhen going into the hospital or receiving health system care
Getting the wrong medications 61%
Negative interaction of medications 58%
cost of treatment 58%
Procedural complications 56%
Having enough drug information 53%
Getting an infection during stay 50%
Suffering from pain 49%
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Top Patient Concerns in Emergency Departments - National
Concerns elicited from telephone Interviews with 767 patients receiving care in ED
• Misdiagnosis-22%• Physician Errors-16%• Medication Errors-16%• Nursing Errors-12%• Wrong test/procedure-10%Burroughs, TE, et al, Acad Emerg Med, 2005
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What our patients (KP) are telling us
Patient safety to our patients means Proper diagnosis and treatment Sound communication – listening to the
patient Competent and Caring Staff Complete and accurate medical records Access to providers including specialists Lab tests when
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What our patients (KP) are telling us
Medical mistakes were defined by patients as
Chart mix-ups Contamination Misdiagnoses Misidentification Exposure to infections, Wrong or inappropriate medications.
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What our patients are telling us (continued)
Why our patients think medical mistakes occur Inadequate staffing Inexperienced staff Inadequate time spent with patients Incomplete knowledge of a patient’s medical history Medication errors and possible interactions of
medications Not checking patient medications for possible
interactions Not taking the time to get to know patient or understand
their problems
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What our patients are telling us (continued)
How patients perceive their role Need to be proactive to prevent further
medical mistakes Need to communicate fully and honestly
with their caregivers, and providers need to listen
Ask questions and speak up (although some said that they would not be comfortable doing this)
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Medical Office Safety
Medical errors and preventable events
--23.6% of 351 outpatient encounters
Elder et al, “dentification of Medical Errors by Family Physicians during Outpatient Visits” Annals of Family Medicine 2: 125-129
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Medication errors
Errors were present in 68% of all medication-related malpractice claims
The majority (62%) of these were outpatient-related
Medication errors broken out (outpatient): Ordering: 45% Transcribing: 4% Dispensing: 34% Administration: 21% Monitoring: 38%
* Data from the Malpractice Insurer’s Medical Error Prevention Study (MIMEPS)* Data from the Malpractice Insurer’s Medical Error Prevention Study (MIMEPS)
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Medications most commonly involvedData from the Malpractice Insurer’s Medical Error Prevention Study (MIMEPS)Data from the Malpractice Insurer’s Medical Error Prevention Study (MIMEPS)
Inpatient Electrolytes 14% Narcotics 13% Antibiotics 10% Anticoagulants 8%
Outpatient Antibiotics 19% Antidepressant 11% Narcotics 7% Oral steroids 5%
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Adverse drug events in Medical Office
• 25% of 661 patients• 63% were associated with physician failure to
respond to medication-related symptoms• 37% were associated with patient failure to inform
the clinician• Medication classes most frequently involved
SSRI – 10% Beta Blockers – 9% ACE inhibitors – 8% NSAIDS – 8%
Gandhi et al, Adverse drug Events in Ambulatory Care, NEJM 348:1556-1564, April 17, 2003
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Outpatient Medication Safety Assessment-KP
Incomplete orders
Inadequate/incomplete drug-allergy alerting
Inappropriate use and/or response to verbal orders
Incomplete/inadequate i.e. non-compliant) patient identification practices
LA/SA and labeling issues
Inappropriate (i.e. unsafe) storage of medications
Lack of independent double-checks, where needed/appropriate
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Why is this so hard?Complexity
Powerful drugsHighly technical equipment/productsRapid decisions; time pressuredMany care givers; multiple “handoffs”Task-based versus Systems-based
Limited resources
Complex human factors
High acuity illness / injuries
Ambient environment prone to distraction
Variable patient volume; variable patient flow
Staff
Management System
Equipment/Technology
Environment
Patient
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Accident Causation Model - Swiss Cheese
Modified from Reason, 1991 © 1991, James Reason
NURSE MD
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Result of Our Current Error Model: Cycle of Error
BadOutcome
RetrospectiveReview
Classification
OvertMechanical
Failure
ComplexSystemFailure
HumanError
Remedialaction
More complex,brittle system
Shift in lociof failures
Quietperiod
15%
0%85%Copyright © 1997 by Richard I. Cook, M.D.
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Why is this so hard
• Trained to be perfect• Well trained individuals will deliver error-
free performance if they are paying attention and trying hard
• Shame, blame, train• Culture is so pervasive, what’s the use of
trying?
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Why is this so hard?
• We have always done it that way
• Never happens here phenomenon
• We can’t afford it-takes too much time
• It’s not convenient
• What you have to say is not important
• What I have to say is not important
• Technology will fix the problem
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Why is this so hard?—the human condition
Limited memory capacity
Limited mental processing capacity
Limits imposed by stressors
Limits imposed by fatigue and other physiological factors
Compounded by: poor group dynamics Unrealistic attitudes Staffing challenges Environmental factors
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Drifting/Migration
Clinical work is founded on tried and tested ways of diagnosing and treating patients
Flexibility is necessary adaptation to changing circumstances
Drifting is casual and inappropriate departure from good clinical practice
Generally starts out with plausible reasons for breaking a rule
Moves into ignoring rules Migrates into becoming socially accepted
and perhaps organizationally sanctioned
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Drifting—what makes an organization vulnerableBlaming front line workers
Denying the existence of systemic error
Pursuit of productivity and financial indicators
Leads to quick fixes solving the immediate problem but ignoring the underlying problems
Reason
Tucker and Edmonson
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Drifting—masking the problem
Insidious—happen over time
Absence of incidents
Tolerance by management because nothing “bad” happens
Tendency to become more lax over time
Vaughn
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“LEGITIMATE” SAFE SPACE
“ILLEGITIMATE” SAFE SPACE
“ILLEGITIMATE”NOT SAFE
Potential Event
Policy/Procedures
“work-a-rounds”
VERY SAFE SAFE UNSAFE
The world of work
G. Eric Knox, MDProfessor, OB-GYNUniversity of Minnesota
Renee Almaberti – Systems Migration to Boundaries
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ARE WE DRIFTING?
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What you can do
Ensure staff are provided training and education that allows them to perform their job safely.
Encourage the active engagement of staff in safety related activities.
Recognize and reward staff for working safely. Create and maintain a climate of “psychological safety”
where it is easy for staff to speak up, including reporting what is getting in their way of performing safely.
Address identified safety issues in a timely manner.
Provide relevant data and information to staff that further increases their situational awareness and understanding of safety-related risks and hazards.
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What you can do
Communicate your expectations to staff concerning their duty to avoid unsafe (i.e., “at-risk”) behaviors and report errors and unsafe conditions.
Conduct routine observations, and through conversation and coaching, help staff make safer choices and reduce their own tolerance for risk-taking.
Remove incentives for unsafe behaviors and respond to them, regardless of outcome, in a “just manner”.
Ensure line managers are accountable for the safety performance of their employees.
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“Safety-Focused” Activities
Safety Walkarounds
Huddles, Briefings, and Debriefings
Use of SBAR
Observation and Coaching
Incident Investigation…to Learn
Application of “Just Culture” principles