Preventing Medical Errors:

A Team Approach

Safety Improvement and Error Reduction Through Understanding

Presented by:

Cynthia A.Mikos, Esq.Cynthia A. Mikos, P.A.

cmikos@camlaw.netwww.camlaw.net

Objectives

• All participants will be able to describe: – Root cause analysis– Error reduction and prevention measures – Patient safety processes

Additional Objectives for Nurses

• Factors that impact the occurrence of medical errors

• How to recognize error prone situations• Processes to improve outcomes• Responsibilities for reporting• Safety needs of special populations• Factors important for public education

Additional Objective for Physicians

• Identify the five most misdiagnosed conditions as established by the licensing board

Additional Objectives for Physical Therapists

• Education for physical therapists must also encompass:• Medical documentation and communication • Contraindications and indications of physical

therapy and patient management • Pharmacological components of physical

therapy and physical management.

Caution

• The information presented today is intended as a broad overview of error in healthcare, presented in good faith conformance with Florida statutory and administrative code requirements. This information is for educational purposes and should not be construed as legal advice. The information presented generally reflects the views of this particular author.

Medical Error is a Public Health Nightmare

• The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering. (Chassen et al., 1998)

Select Resources for Patient Safety Information

• Agency for Healthcare Research and Quality www.ahrq.gov

• Institute of Medicine of the National Academies www.iom.edu

• The Joint Commission www.jointcommission.org

• Institute for Safe Medication Practices www.ismp.org

• National Patient Safety Foundation http://npsf.org/

Error Definition

• Multiple definitions and understandings of what constitutes medical error

• IOM definition– Errors are failures of planned actions to be

completed as intended (error of execution) or the use of wrong plans to achieve what is intended (error of planning) May be acts of commission or omission

– Harm is not required

Adverse Event Definition

• Adverse events – injuries caused by medical intervention (not health condition of patient)

• A large proportion of adverse events are the result of errors and are known as Preventable Adverse Events

• Adverse drug event – any injury due to medication

Who to Blame?

• Individuals - who are faulty or weak• The system - an interdependent

interaction of multiple human and non-human elements

Human Contributions to Errors

• Active failures – front line workers who operate the technology which interfaces with the patient

• Latent conditions – factors in the system that are designed by humans but are not under the direct control of front-line workers

Error Process

• Organizational processes• Create error producing environment • Caregiver makes an error at human end

of interface• Breaching of safety protocols• Bad outcome results

People Factors in Error

• Fatigue• Interruptions• Unfamiliar situations• Miscommunication • Heavy workload

Process Factors in Error

• Variable input • Complexity• Inconsistency• Tight coupling

Collection of Error Data

• 27 states with systems for hospitals to report adverse events (26 mandatory)

• Sentinel event reporting through JCAHO• Voluntary reporting through various

organizations such as the Institute for Safe Medication Practices

Reportable Events • Vary by state and accrediting bodies• Tension between accountability and

improving patient safety• Florida definitions of reportable events-

– Slightly differ by setting where the adverse incident occurs

• Hospital or ambulatory surgery center• Physician office• Nursing home

Florida’s Mandatory Reporting for Hospitals

• Adverse Incident- an event over which health care provider exercises control … which:– Results in 1) death, 2) brain or spinal damage, 3)

permanent disfigurement, 4) fracture or dislocation of bones or joints, 5) neurological, physical or sensory limitation post discharge, 6) specialized medical attention or surgical intervention, 7) transfer

– Wrong surgery (patient, site, procedure)– Required unanticipated surgical repair– Removal of unplanned foreign objects post op

Florida Board of MedicineMost Misdiagnosed Conditions

• 1) Wrong-site/patient surgery• 2) Cancer• 3) Cardiac• 4) Timely diagnosis of surgical

complications• 5) Failing to diagnose pre-existing

conditions prior to prescribing contraindicated medications

JCAHO Sentinel Events• Sentinel event not synonymous with medical

error • Defined as: An unexpected occurrence

involving death or serious physical or psychological injury or risk thereof. Serious injury includes loss of limb or function

• Accredited institutions must identify and respond to all sentinel events, including a root cause analysis

• Reporting to JCAHO voluntary

Sentinel Event Statistics• Published on JCAHO website• From 1/95 to 12/07 4,817 reports• Mostly from general hospitals (67%),

psych facilities or units (20%), ED (4%), LTC (3%)

• Death as outcome (70%)• Most reported event – wrong site surgery

(13%)

Error Reduction and Prevention Measures

• Collection of error data• Education and setting of national safety

goals• Systems process changes• Root cause analysis of errors

Patient Safety Organizations• Patient Safety and Quality Improvement Act of

2005 • Congress creating federal regulations to protect

the confidentiality of information collected by patient safety organizations

• Proposed rule issued 2/12/08 in Vol. 73, No. 29 Federal Register page 8112

• Proposed rule criticized for limited protections offered

2008 National Patient Safety Goals

• To promote specific improvements in patient safety

• JCAHO sets annual goals guided by advisory group of experts in patient safety- systems engineers, health care providers, and technical types

• Individualized by facility type – hospital, LTC, etc.

Sample 2008 NPSGs and Recommendations for Hospitals

• Improve accuracy of patient identification– Use 2 identifiers

• Improve staff communication– Read back verbal orders, create a “do not use” list

of abbreviations, measure timeliness of getting critical lab results to the responsible caregiver, standardize approach to “hand off” communications

More Sample Goals

• Improve the safety of using medications– Identify and annually update look-alike,

sound-alike drugs and implement protections– Label all meds and containers like syringes,

medicine cups or basins even on sterile fields– Reduce the likelihood of patient harm

associated with anti-coagulant therapy

More Sample Goals

• Improve recognition and response to changes in a patient’s condition– The organization selects a suitable method

that enables health care staff members to directly request assistance from a specially trained individual when a patient’s condition appears to be worsening

Education with a Bite

• Effective October 2008, Medicare will not pay hospitals when they make certain errors nor can the patient be billed for costs associated with errors

• Forcing hospitals to pay attention to patient safety due to financial impact

• No pays:– UTI or sepsis from catheters, falls, decubiti, retained

surgical items, blood incompatibility, mediastinitis post heart surgery, and air embolism, (3 more to be added next year)

Systems Process ChangesStructure, Environment, and People

• Simplification• Standardization• Process design includes prompts• Elimination of sound/look-alikes• Environment/product improvements• Training• Teamwork• Communication

Root Cause Analysis

• Retrospective error analysis to identify the basic or causal factors that underlie variation in performance

• Should focus primarily on system and processes, not on individual performance

• JCAHO has specific requirements

Special Population Safety Considerations

Pediatric Safety

• What makes sick kids safety hazards?• What makes healthcare delivery

hazardous for kids?• How can we make healthcare delivery

safer for kids?

Safety for the Chronically Ill

• What makes the chronically ill safety hazards?• What makes healthcare delivery hazardous for

the chronically ill?• How can we make healthcare delivery safer for

our chronically ill?

Cultural Competence and Safety

• Language barriers• Social-behavioral differences• Literacy

Multifaceted Teams

• Physicians• Nurses• Pharmacy • Respiratory therapy• Physical, occupational and speech therapy• Radiology• Social services• Lab • Dietary• Transportation

Patient Inquiry

• OTC medications• Alternative therapies• Allergies/side effects• Knowledge of diagnosis and treatment

plan information

Helpful Websites for Patients

• JCAHO “Speak Up” program– http://www.jcaho.org/general+public/patient+safety/speak+up/index.htm

• AHRQ Patient Safety Directory Page– http://www.ahcpr.gov/qual/errorsix.htm

What’s Necessary?• More information and analysis of errors with evidence

backed system and process solutions• More education of health care providers and

consumers• Culture change inside health care delivery systems• Changing the culture of blame

– Reasons for changing the culture of blame– Legal impediments – Creating the right legal/research environment