Diseases  of  Heart  

Malignant  neoplasms   Medical  Errors  

Chronic  Lower  Respiratory  Diseases  

Accidents  (Uninten>onal  

injuries)  

Cerebrovascular  diseases  

Alzheimer's  disease  

Diabetes  mellitus  

Influenza  and  pneumonia  

Nephri>s,  nephro>c  

syndrome  and  nephrosis  

Inten>onal  self-­‐harm  (suicide)  

Deaths   611,105   584,881   305,000   149,205   130,557   128,978   84,767   75,578   56,979   47,112   41,149  

0  

100,000  

200,000  

300,000  

400,000  

500,000  

600,000  

700,000  

Num

ber  o

f  Deaths  

Deaths  in  the  United  States  (2012-­‐2013)  

Primum non nocere: (“First, do no harm”)Applying Business Principles to Analyze Medical Errors

By: Hadiqa Memon, Dr. Elizabeth Anderson-Fletcher

DEFINING MEDICAL ERRORS

PROBLEM STATEMENT:Medical errors received national attention in the early 2000s after the Institute of Medicine published To Err is Human: Building a Safer Health System. In this report, researchers argued that medical errors were the eighth leading cause of death. They estimated that 44,000 to 98,000 deaths occur annually in the United States as the result of medical errors (Kohn et al., 2000).

A decade later, medical errors are growing in concern, and are estimated to be the third leading cause of death in the United States (James, 2013). While there are many organizations trying to find ways to improve patient safety, there is still much left in explaining medical errors. MEASURING MEDICAL ERRORS

CURRENT STATISTICS

IMPROVING QUALITY

HOW DO ERRORS OCCUR?

PROPOSED MODEL:

REFERENCES:

CONCLUSION:

KEY FINDINGS:

Case: Description:

Betsy Lehman Dana-Farber

Cancer Institute(Boston, MA)*

• 39-year old health reporter for the Boston Globe was diagnosed with breast cancer in September 1993

• She began her third round of chemotherapy on November 14, 1994.

• On December 2, Lehman’s electrocardiogram revealed low potassium levels, for which she was prescribed potassium supplements.

• On December 3, Lehman died due to accidental overdose of chemotherapeutic drug (Cytoxan).

• On February 13, 1995, data clerk found that Lehman’s death resulted from a medical error.

Thomas E. Duncan

Texas Health Presbyterian

Hospital(Dallas, TX)**

• A Liberian national who had unknowingly contracted Ebola from a neighbor in Monrovia on September 15, 2014.

• He arrived in Dallas on September 20.• He began to feel ill on September 24 and went

to THPH emergency room on September 25.• He was misdiagnosed to have a low-grade

virus and sent home with prescribed course of antibiotic and Tylenol

• On September 28, his condition worsened and he was placed in isolation.

• On September 30, he was diagnosed with Ebola and later died on October 8.

• The two nurses treating Duncan were also diagnosed with Ebola on October 12 and 15 and transfered to biocontainment units.

• Anderson-Fletcher, E., Vera, D., & Abbott, J. (2016). The Texas Health Presbyterian Hospital Ebola Crisis: A Perfect Storm of Human Errors, Systems Failures, and Lack of Mindfulness, Hobby Center for Public Policy White Paper, University of Houston.

• Bohmer, R., & Winslow, A. (1999). The Dana-Farber Cancer Institute, HBS Case.• Classen, D. C., Resar, R., Griffin, F., Federico, F., Frankel, T., Kimmel, N., James, B.

C. (2011). “Global trigger tool” Shows that Adverse Events in Hospitals may be Ten Times Greater than Previously Measured, Health Affairs, 30(4), 581–589.

• Deming, W. Edwards. (1986). Out of the crisis, Massachusetts Institute of Technology Center for Advanced Engineering Study, Cambridge, MA.

• Heron, M. (2016). Deaths: Leading Causes for 2013, National Vital Statistics Reports, The Centers for Disease Control and Prevention National Center for Health Statistics, National Vital Statistics System, 65(2), 1–95.

• James, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care, Journal of Patient Safety, 9(3), 122–8.

• Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To Err is Human: Building a Safer Health System, Annales Francaises D’Anesthesie et de Reanimation (Vol. 21).

• Leape, L. (1994). Error in Medicine, Journal of American Medical Association, 272, 1851–1857.

• Maslow, a. H. (1943). A Theory of Human Motivation, Psychological Review, 50(13), 370–396.

• Reason, J. (2000). Education and Debate Human Error: Models and Management, The British Medical Journal, 320, 768–770.

• Reason, J. (2001). Understanding Adverse Events: The Human Factor, In Vincent C. (Ed.), Clinical Risk Management: Enhancing Patient Safety (pp. 9–30), London: BMJ Books.

• Williams, C., Nelson, D. L., & Quick, J. C. (2012). Introduction to Organizational Behavior and Management, (M. S. Maureen Staudt, Ed.), Mason: Cengage Learning.

• Wills, M. (2016). Personality Hardiness, Resilience, and Compassion Fatigue in Traumatic Brain Injury Rehabilitation Workers, Honors Thesis, University of Houston.

CASE STUDIES:

*(Bohmer and Winslow, 1999) **(Anderson-Fletcher, Vera, & Abbott, 2016)

• Business principles of Management and Supply Chain offer a new perspective to the current research in medical errors, which can ultimately improve the quality of the healthcare.

• In order to reduce medical errors, it is essential to build a culture of transparency, where errors are not a search for the culprit, but a lesson from which to learn and improve upon.

• Furthermore, it is essential to understand the needs of healthcare professionals, by incorporating best practices from the management literature to create satisfying occupations.

ACKNOWLEDGMENTS: This project was possible by the support of The University of Houston Honors College and The Office of Undergraduate Research.

94% of errors are attributed to the system, while 6% are special cases. (Deming, 1986)

Understanding the needs of healthcare professionals:

• In the last fifty years, there has been a shift from outcome-dependent to process-dependent approaches in defining the term “medical errors”.

• The spontaneous nature of medicine has made measuring medical errors difficult. However, the Institute of Healthcare Improvement has been developing and refining the Global Trigger tool to obtain a better estimate.

• Based on the estimates from the Global Trigger tool, medical errors are the third leading cause of death. Despite the growing concern of medical errors, the National Vital Statistics fails to report adverse medical events.

• It is essential to understand that human errors are part of larger system failures in the healthcare industry.• The culture of medicine is synonymous with the “culture of blame.” Attention has been focused on finding the person

responsible for the error, rather then understanding what caused the error.• Management literature offers new perspective in improving the quality of healthcare service.

Institute for Healthcare Improvements Global Trigger tool (90%)

Deviation from the process of care, which may or may not cause harm

to the patient.(Reason, 2001)

Agency for Healthcare Research and Quality’s

Patient Safety Indicators (9%)

Hospital Voluntary Reporting

System (1%)

Effectiveness of current measuring tools:

Factors that affect healthcare employee productivity:

OCCUPATIONAL PHYSIOLOGICAL PERSONAL• Work Environment• Culture of Medicine,

“Culture of Blame”• Occupational Stress• Communication

Barriers• Management vs.

Clinical

• Shift Cycle • Sleep Patterns• Nutrition• Exercise, Physical

Activity• General Health and

Wellness

• Family Responsibilities

• Personal Responsibilities

• Relationship Status• Children• Work/Life Balance• Educational Stress• Financial Stress• Job Satisfaction

• Increased Stress, High Cortisol Levels• Exhausted Mental State

• Compassion Fatigue• Burnout

Decreased Worker Productivity and Work Quality

(Classen et al., 2011)

The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim, the

accumulation of errors results in accidents.

(Leape, 1994)

(Kohn et al., 2000)

Any combination of active or latent errors:active errors: occur at the level of the frontline operator.

latent errors: tend to be removed from the direct control of the operator and include practice, products, procedures,

and systems.(Reason, 2000)

“When a

docto

can

not do

go d, he must be kept f o do ng ha m.”

-Hippocrates

National Vital Statistics (Heron, 2016)

Job Performance = Motivation x Ability x Situational Constraints(Williams, Nelson, & Quick, 2012)

• Offering fair compensation and comfortable working conditions.

• Safe working environment, job security, and fringe benefits.

• Encouraging social interaction and cooperation, creating stable group settings.

• Recognizing/rewarding outstanding performance, job satisfaction/importance, giving employees responsibilities.

• Challenging employees’ abilities, providing opportunities for advancement, encouraging creativity and high levels of achievement.

Healthcare Quality Improvement Organizations:

An act of omission or commission in planning or execution that contributes to an unintended result.

MEDICAL ERRORS ALLEGEDLY 3RD LEADING CAUSE OF DEATH

*An estimated 210,000 - 400,000 deaths annually in the United States due to medical errors.

(James, 2013)

(Maslow, 1943)

(Williams, Nelson, & Quick, 2012; Wills, 2016)Deaths in the United States (2012-2013)

Num

ber

of D

eath

s

BETSY LEHMAN THOMAS DUNCAN

Nurses used to

unusual drug dosage, therefore

administered treatment based

on protocol.

Physician unaware of prescription

protocol used by nurses.

Lehman’s symptoms

understood as side effects for her treatment.

Duncan’s misdiagnosis

exacerbates his symptoms.

Miscommunication between physicians

and nurses.

Electronic form did not immediately

highlight Duncan’s travel.

Self-Actualization

Self-Esteem

Belonging

Safety/Security

Physiological

Adverse events as a result of medical errors.