Reducing Medical Errors, Reducing Medical Errors, Promoting Patient SafetyPromoting Patient Safety

Sharon Levine, MDSharon Levine, MDAssociate Executive DirectorAssociate Executive DirectorKaiser PermanenteKaiser PermanenteOctober 20-21, 2008October 20-21, 2008Beijing, ChinaBeijing, China

Primum non nocerePrimum non nocere - Hippocrates - Hippocrates

Every Patient’s RightEvery Patient’s RightEveryone’s ResponsibilityEveryone’s Responsibility

“ “Medicine used to be simple, effective and Medicine used to be simple, effective and relatively safe - now it is complex, effective, relatively safe - now it is complex, effective, and potentially dangerous”and potentially dangerous”

Sir Cyril ChantleSir Cyril Chantle

“ “44,000-98,000 patients die each year in 44,000-98,000 patients die each year in hospitals from medical error” hospitals from medical error” IOM report IOM report May be as May be as high as 195,000 deaths per year high as 195,000 deaths per year Health Grades 2004Health Grades 2004

Our Challenge:Our Challenge: Preventing harm to patients from the care Preventing harm to patients from the care

intended to help themintended to help them

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Accidental Deaths in the U.S.

120,000

43,649

14,9863,959 329

0

20,000

40,000

60,000

80,000

100,000

120,000

Medical ErrorDeaths

MVA Deaths Fall Deaths DrowningDeaths

Plane Deaths

(National Safety Council, Harvard School of Public Health, 1999)(National Safety Council, Harvard School of Public Health, 1999)

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How Do We Compare?

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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Top Patient Concerns AboutTop Patient Concerns About Hospital Stays Hospital Stays

Negative interaction of medicationsNegative interaction of medications 58%58%

Getting the wrong medicationsGetting the wrong medications 61%61%

Cost of treatmentCost of treatment 58%58%

Procedural complicationsProcedural complications 56%56%

Having enough drug informationHaving enough drug information 53%53%

Getting an infection during stayGetting an infection during stay 50%50%

Suffering from painSuffering from pain 49%49%

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Basis Of Error– ComplexityBasis Of Error– Complexity

Powerful drugs Highly technical

equipment/products Rapid decisions; time

pressured Many care givers; multiple

“handoffs” Task-based versus Systems-

based

Limited resources Complex human factors High acuity illness / injuries Environment prone to

distraction Variable patient volume;

variable patient flow flow

Staff

Management System

Equipment/Technology

Environment

Patient

66Requires more than “paying attention” and “trying hard”Requires more than “paying attention” and “trying hard”

80% medical error 80% medical error is system derivedis system derived

95% mistakes— 95% mistakes— the good guysthe good guys

Identify and Identify and address the human address the human factorsfactors

Fix the systemFix the system Understand the Understand the

differencedifference

Basis of Error - ComplexityBasis of Error - Complexity

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“Culture of Safety”

Awareness, understanding, and ownership of safety Awareness, understanding, and ownership of safety by all by all

Constant vigilance to prevent errorConstant vigilance to prevent error Learning from errors that do occur, and minimize Learning from errors that do occur, and minimize

chance of recurrencechance of recurrence Teamwork, not hierarchy or autonomyTeamwork, not hierarchy or autonomy Communication and hand-offsCommunication and hand-offs Non-punitive environment - encourage reporting of Non-punitive environment - encourage reporting of

errors and near-misseserrors and near-misses Systems to mitigate “human factors”Systems to mitigate “human factors”

Memory capacityMemory capacity Mental processingMental processing Stressors: fatigue, emergenciesStressors: fatigue, emergencies

88

Behavior

Human error--inadvertently doing other Human error--inadvertently doing other than what should have been done; slip, than what should have been done; slip, lapse, mistake - lapse, mistake - consoleconsole

At risk behavior - behavior where risk is At risk behavior - behavior where risk is not recognized, or is mistakenly believed not recognized, or is mistakenly believed to be justified - to be justified - coachcoach

Reckless behavior - conscious disregard Reckless behavior - conscious disregard of a substantial and unjustifiable risk – of a substantial and unjustifiable risk – remedial, then disciplinary actionremedial, then disciplinary action

David MarxDavid Marx

Biggest barrier to preventing errors – punishing Biggest barrier to preventing errors – punishing people for making mistakespeople for making mistakes

99

“Culture of Systems”

From patient-specific to systems viewFrom patient-specific to systems view Indentifying patterns of errorIndentifying patterns of error Standardization where appropriate: Standardization where appropriate:

processes, procedures, checklists, processes, procedures, checklists, standardized ordersstandardized orders

Care team accountability for error Care team accountability for error identification and eliminationidentification and elimination

Expert team vs. team of experts: Expert team vs. team of experts: communication, simulation, attention to communication, simulation, attention to hand-offshand-offs

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Reduce Hospital Mortality and Morbidity

Infection Reduction

Falls and pressure ulcers

Early goal-directed therapy

High Alert Medication Program

Highly Reliable Surgical Teams

Disease-specific care: AMI, HF, PN, SCIP, CVA, glucose control

Anticipating end of life: Palliative Care, Advance Directives

Access to alternative care settings: SNF, HH, rehab

Goals Drivers Focus Areas & Initiatives

Drivers of Hospital Mortality and Morbidity

Evidence- Based Care

Appropriate Care Setting

No Needless Harm/Deaths

1111

High Alert Medication Program

High Alert Drug ListHigh Alert Drug List Standardize: policies and proceduresStandardize: policies and procedures Education, training and retrainingEducation, training and retraining No-interruption zone, -wearNo-interruption zone, -wear Peer observationsPeer observations Measure, monitor, feedbackMeasure, monitor, feedback Peer group: share learningsPeer group: share learnings Leadership focus, oversightLeadership focus, oversight

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ZoneZoneMedRite

The Zone is an area marked out The Zone is an area marked out in front of the PYXIS to signify in front of the PYXIS to signify a “no interruption” area.a “no interruption” area.

Use of tape is a common zone Use of tape is a common zone indicator in hospitals such as in indicator in hospitals such as in the OR and Pharmacythe OR and Pharmacy

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No Interruption Wear (NIW) is No Interruption Wear (NIW) is the the tooltool that helps minimize that helps minimize interruptions during medication interruptions during medication administration administration

Worn ONLY during the Worn ONLY during the Medication administration Medication administration processprocess

Allows the nurse to be Allows the nurse to be “interrupted” at appropriate “interrupted” at appropriate timestimes

1414

Percentage change from 1st mean (13.23

Jan to June ’06) to 2nd mean (26.0) June to

April ’07: 97%

From April ’07: Days since last event:

445 and counting

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From “Art to Science” – From “Art to Science” – Translating Evidence into BenefitTranslating Evidence into Benefit

Clinical Research

Evidence Implementation Benefit

REDESIGNING PROCESSES

System Redesign for Safety:Highly Reliable Surgical Teams

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Clinical Research

Evidence Implementation Benefit

System Redesign for Safety

Check lists

Teamwork

Time-out

Standardized orders

Safety Summit

Safety team in every OR

Standardized orders

Checklist for every role

Observation/audit

Debrief

Simulation

Training

Report cards

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Early Evidence of Benefit

40% reduction in surgical complications 40% reduction in surgical complications since 2001since 2001

From one surgery-related injury per 48 days From one surgery-related injury per 48 days (2003 to 2007) to one in 280 days (and (2003 to 2007) to one in 280 days (and counting) 2008counting) 2008

Significant and sustained improvement: in Significant and sustained improvement: in abx use/time/duration (97%); normothermia abx use/time/duration (97%); normothermia (95%); beta blocker use (97%)(95%); beta blocker use (97%)

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Early Evidence: Surgical Care Early Evidence: Surgical Care Improvement Program (SCIP)Improvement Program (SCIP)

SCIP Composite of Antibiotic Choice, Timing and Duration

100%

90%

80%

70%

60%

50%

40%

Regional SCIP Performance

Quarter 1 2008

SCIP Abx Timing: 96%

SCIP Abx Choice: 98%

SCIP Abx Duration: 95%

Hair Removal: 99%

Normothermia: 92%

Beta Blocker: 97%

VTE composite: 94%

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