040611-EAES-Barcelon.. - University of Washington

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Transcript 040611-EAES-Barcelon.. - University of Washington

The Nature of Errors
Richard M. Satava, MD FACS
UNIVERSITY
OF WASHINGTON
SCHOOL OF
MEDICINE
Professor of Surgery
University of Washington School of Medicine
and
Program Manager, Advanced Biomedical Technologies
Defense Advanced Research Projects Agency (DARPA)
and
Special Assistant, Advance Medical Technologies
US Army Medical Research and Materiel Command
12th International Congress
European Association for Endoscopic Surgery
Barcelona, Spain
June 11, 2004
Institute of Medicine
Definition of Errors
• Failure of a planned action
to be completed as intended
• The use of a wrong plan to achieve an aim
Patient Safety Foundation
Definition of Errors
An unintended healthcare outcome caused by
a defect in the delivery of care to a patient
Health care errors may be of:
- Commission (doing the wrong thing)
- Omission (not doing the right thing)
- Execution (doing the right thing incorrectly)
Errors may be made by any member of the health care team
in any health care setting
Evidence on Surgical Errors
Surgical adverse events
•1/50 admissions in Colorado and Utah hospitals -1992
•Accounted for two-thirds of all adverse events
•1 of 8 hospital deaths accounted for by surgical errors
Two Major Classes of Errors
1.
Systemic
A series of errors resulting in an
adverse event
2.
Specific
A specific event which in itself is
an error
Lucian Leape Classification
• Diagnostic Errors or delay in diagnosis
Failure to employ indicated tests
Use of outmoded tests or therapy
Failure to act on results of monitoring or testing
• Treatment Error in performance of an operation, procedure, or test
Error in administering treatment
Error in dose or method of using a drug
Avoidable delay in treatment or response to abnormal test
Inappropriate care
• Preventive Failure to provide prophylactic treatment
Inadequate monitoring or follow-up of treatment
• Other
Failure of communication
Equipment failure
Time of Occurrence
•Proximate - Those errors which occur before the actual critical event
• They are not full errors in their own right
• They can be corrected or “recovered”
• If unrecognized, compound (“chain of events”) into an error
•Coface - Those errors that are the direct cause of the adverse event
• Is the actual event which is identifiable as the “error”
• If recognized, may/may not allow to be “recovered”
• If unrecognized, inevitably results in a complication
•Subsequent - Those errors which occur after the critical event
• An error which would not have occurred without previous event
• May/may not be “recovered”
• Often requires subsequent “remediation” or correction.
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