SUB TITLE HERESuzanne Graham, RN, PhD

Patient Safety Patient Safety

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

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?

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

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

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)

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)

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

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%

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

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

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.

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

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)

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

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)

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%

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

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

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

Accident Causation Model - Swiss Cheese

Modified from Reason, 1991 © 1991, James Reason

NURSE MD

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.

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?

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

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

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

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

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

“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

ARE WE DRIFTING?

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.

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.

“Safety-Focused” Activities

Safety Walkarounds

Huddles, Briefings, and Debriefings

Use of SBAR

Observation and Coaching

Incident Investigation…to Learn

Application of “Just Culture” principles