Marwan GHOSN,MD, MBA/MHM

Patient’s Safety: Could It Truly Be This Awful?

Objectives

Sensitize the audience on the dimension of the problem

Define the medication error and its impact on Patient Safety and Healthcare System

Emphasize on the role of nurses on Patient Safety Quality and Patient Safety Hospital Accreditation

Six Key Aims of Health CareSafety Comes First !

Safe – avoid injuries to patients Effective – based on science Patient centered – respectful,

responsive Timely – reduces wasteful delays Efficient – avoid waits Equitable – across gender, race,

location, and ability to pay

April 20, 2023April 20, 2023 When Mistakes are not an OptionWhen Mistakes are not an Option 44

Medication Errorsin numbers

April 20, 2023April 20, 2023 When Mistakes are not an OptionWhen Mistakes are not an Option 55

> 1,000,000

Serious Medication Errors per year

in USA...Ref: Wall Street Journal/Institute of Medicine

195,000 hospital deaths

per year in the U.S.as a result of healthcare error

2000-2002Source: Boston Globe – 27.July.2004

HealthGrades / Denver

44,000 preventable

deathsoccur each year

Source: Boston Globe – 27.July.2004

HealthGrades / Denver

“When I climb Mount Rainier I face less risk of death than I’ face on the operating table.”

Donald Berwick*, “Six Keys to Safer Hospitals: A Set of Simple Precautions Could Prevent 100,000 Needless Deaths Every Year,” Newsweek (12.12.2005)

*Donald Berwick is the President & CEO of the Institute of Healthcare Improvement (IHI)

Tommy Thompson, Secretary of the United States Department of Health & human

Services (2001-2005):"Some grocery stores have better technology than our hospitals and clinics.”

Source: Special Report on technology in healthcare, U.S. News & World Report (07.04)

1010

Do these numbers give you a pause

when you will decide

to go to the hospital ?

11

What is “Medical Error”?

12

Definition of a Medication Error

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.

13

Medication Error include Delayed diagnoses Mistakes during treatment Medication mistakes Delayed reporting of results Miscommunications during transfers and transitions

in care Inadequate post-procedure care Mistaken identity

14

Medication Error include

Error of commission: Act of doing something incorrectlyUnder normal circumstances that don’t include

stress & time pressures: 3 times out of 1000 Errors of omission:

Something that should be done are not doneIn the absence of reminders: 1 time in 100

Examples

Transdermal patches

•Appliance of the new patch directly on top of the old one. •Not removal of the protective linear•Not removal of the old patch when the new patch is applied.•Difficult to find “clear” patches on the skin•Accidental and intentional ingestion

Medication Error-prevention Strategies

Educational and competency requirements for practitioners Organized and up-to-date patient medical record and

medication profile Coordinated care among practitioners. Standardized medication ordering system:

Preprinted medication order forms Computerized prescriber order entry system Standardized format for medical order content including:

dosage calculations, vocabulary and nomenclature, abbreviations, dosage limits and routes of administration.

Medication Error-prevention Strategies

Standardized protocols for prescribing, preparation, dispensing, and administration of medication: Medication-order verification system (9 checkpoint system) Documentation such as checklists, worksheets to calculate

dosages and administration rates, and treatment flow sheets Cross-checking

Manual or electronic medication monitoring Patient and caregiver education

Medication Error-prevention Strategies

Quality assurance: Periodic auditing of

practitioner proficiency Error reporting system Analysis and resolution of

medication errors Periodic re-evaluation of

medication use system

What are the impacts of medical error?

Harm to the patient Moral Imperative Professional Imperative Financial Imperative

Let’s have a look on some concrete numbers ……

2020

Medical errors result in injury cost $17 to $29 Billion each year in USA

Ref: Kohn LT, Corrigan JM, Donaldson MS (eds). Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Building a Safer health System. Washington, DC: National Academies Press; 1999.

Nosocomial bloodstream infections prolong a patient’s hospitalization

by a mean of 7 days =>

Cost per bloodstream infection range

$ 3,700 and $ 29,000

Ref: Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted, cohort study. Infection Control and Hospital Epidemiology. 1999; 20 (6): 396 – 401.

Preventable Adverse drug events increase in length

stay of 4.6 days at a cost of $

4,685 each

Ref: Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted, cohort study. Infection Control and Hospital Epidemiology. 1999; 20 (6): 396 – 401.

23

Focusing On Nursing !

Nurse Staffing, Quality of Care & Outcomes

Educational levels of hospital nurses and surgical patient mortality

JAMA 2003

Nurse Staffing and impact on clinical outcome

Nurse care for

8 pts

Nurse care for

4 pts

Risk-adjusted mortality rates following common inpatient surgical procedures

+ 31 %

Failure to rescue rates would be expected to prevent 5 deaths per 1000 pts

Ref: Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987-1993. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623. Aiken LH, Clarke SP, Sloane DM, for the International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national findings. Int J for Qual Health Care. 2002;14:5-13.

Education and work environment impact on clinical outcome

Every 10% increase in the proportion of a hospital’s staff nurse workforce with a baccalaureate degree or even higher levels of education is associated with a 5% decline in mortality.

Hospitals with better nurse work environments have fewer adverse patient outcomes than hospitals with poorer work environments.

Turnover rateExperience of Hackensack Hospital

in New Jersey

Relates its low voluntary turnover rate of RN (6.3%) to the excellent practice environment for nurses.

This translates into savings of $ 45,000 to $ 68,000 in recruitment & training expenses for each nurse.

A low turnover rate is associated with a culture that supports patient safety

The nursing practice environment is critical to patient safety, quality of care & nurse retention.

Leape & Berwick, JAMA 2005

Significant progresses have been made when looking at local results under surveillance

Micro Results:Significant Progress

No

system

bey

on

d

this

po

int

10-2 10-3 10-4 10-5 10-6

Civil Aviation

Nuclear Industry

Railways (France)

Chartered FlightHymalayamountaineering

Road Safety

Fatal risk

Anesthesiology ASA1

Fatal Iatrogenic adverse events

Microlight or helicopters spreading activity

Very unsafe Ultra safe

But much little progresses when looking at macro results…

Cardiac Surgery Patient ASA 3-5

Medical risk (total)

Chemical Industry (total)

Global shift: safety improvement along time of all human activities (order of magnitude : one log every 20 years) but the relative ranking of activities does not seem to change

Macro Results:Little Progress

Conclusion (1) The environments in which nurses work are complex systems

that are prone to error.

Errors in nursing care are rarely due to carelessness or incompetence.

Consequently, the culture of health care organizations, created in part by nurses, needs to be “blame free”.

A learning environment, with free flowing open communication enables nurses to identify, discuss and ultimately prevent health care errors.

Conclusion (2)

Patients deserve and have a right to care that minimizes the likelihood of errors and that puts their safety first.

To achieve that aim, nurses and other stakeholders in health care have significant work ahead.

Don’t Wait for

someone else

Safety Begins

with you