Transcript Lecture - TEDNETS

Reducing Errors
Preventing Injury
Saving Lives
Peggy G. Duke, M.D.
Associate Professor Emeritus,
Department of Anesthesiology
Division of Cardiothoracic Anesthesiology
Emory University School of Medicine
September 15, 2015
Developing A Culture of Safety
Easy to say, hard to do
At the most fundamental level reducing errors in
medicine requires a shift in paradigm
Unwavering commitment and accountability
Organization’s leadership CEO, COO, CFO
Physician leadership
Nursing leadership
Departmental Chiefs
Frontline personnel
Physician role in changing the culture
Acquiring new knowledge & skill sets
Assuming leadership roles in quality initiatives
Making practice changes based on new knowledge
Monitoring changes and revising when necessary
Working collaboratively with administrative, quality team
departmental, nursing and frontline personnel
Helping develop evidence-based safety-driven protocols
In Medicine
In building and sustaining a
culture of safety
Physicians lack of ownership of quality initiatives
Errors Occur Worldwide with Alarming Frequency
Physicians, nurses, patients, all healthcare
personnel, and hospital leaders need to
 Grasp the scale of the problem
 Accept that errors are common
 Understand the need to change to a culture that
views errors not as human failures but as
opportunities to improve a faulty system
Institute of Medicine (IOM) 1999
Major Points
1. 100,000 patients die in US hospitals annually as a
result of medical errors
2. ~1 million excess injuries
3. 70% of the adverse events are likely preventable
4. Problem of accidental injury is serious
5. Cause is not careless people but faulty systems
6. Priority: redesign our systems to reduce errors
7. Patient safety must become a priority
To Err is Human: Building a Safer Health System
Kohn LT, Corrigan JM, Donaldson MS, eds.
Washington, DC: National Academy Press; 1999.
Annualized estimate of drug related errors
resulting in additional care in US
(includes non-hospital care, office visits, etc.)
116 million extra visits to a physician
76 million additional prescriptions
17 million ER visits
8 million admissions to hospital
3 million admissions to long term care
199,000 additional deaths
Total cost $76.6 billion/year
Am J Health Syst Pharm. 1997 Mar 1; 54(5):554-8
2013
Estimated patient harm in US hospitals
Preventable
Deaths > 400,000/year
Serious harm > 4 - 8 million /year
Evidence-based estimate of patient harm
In US hospitals
James; J Patient Safety 2013; 9: 122-128
Errors are underestimated
X
4-8 X
Many errors do not produce injury
Some errors are caught before reaching patient
Many patients are incredibly resilient
Sometimes we---patient & clinician-- get lucky
Medical errors occur
Worldwide
With alarming frequency
In all settings
Cause serious harm or death
Estimated that 10-20% of all health care
encounters result in harm to patients
Basic Concepts of Human Error
Reason, JT
1990 Cambridge, England:
Cambridge University Press
Errors inevitable part of being human
Errors are made by highly skilled, highly intelligent, conscientious
professionals who hold themselves to very high standards
Error primarily results from latent errors caused by flaws in systems
processes:
Design
Organization
Training
Management
Common Types of Human Errors
Omission = failure to do
Missed diagnosis
Delayed evaluation
Failure to prescribe needed drug
Inadequate evaluation for respiratory depression
Commission = doing the wrong thing
Giving wrong drug
Operating on wrong side
Ordering wrong drug/wrong dose
Giving opioid to patient with undiagnosed respiratory depression
Communication
Failure to give vitally important information, i.e., allergy, last
dose of antibiotic, difficult airway
Lack of leadership
at CEO & other levels
Understaffing
Inadequate
equipment
Lack of
Inconsistent
expectations
resources
Lack of
Inexperience
physician
Poorly trained
engagement
Creating fear
Fatigue
Distractions
Fear to
Gave wrong drug
speak up Forgot crucial
…Poorly designed processes…
detail at handoff
Gave wrong blood
Forgot to do diabetic
foot , eye exam
Inadequate monitoring
for
respiratory
depression
Incorporate proven safety principles
Train staff
Principles of human error
Quality improvement techniques & approaches
Practice evidence-based or evidence-informed medicine
Harness the use of forcing functions
e.g., e-prescribing with alerts and other computer assisted
functions
Design team-based, protocol-driven approaches
Especially important in highly complex environments
Incorporate proven safety principles
Standardize
equipment, supplies, & processes
Establish interdisciplinary teams
discuss safety issues & problems in work environment
Understand your work environment
where are the breakdowns, bottlenecks, dangers?
Remove fear
everyone should feel safe to speak up when concerned
Stop “blame the person” mentality
Systematically design safety into processes of care
Incorporate proven safety principles
Develop checklists for handoffs
Read out loud, in order, check off as acknowledged
Develop surgery & procedural checklists
Read out loud, in order, check off as acknowledged
Identify and communicate critical situations with
“Repeat Back to Verify” similar to airline safety instructions
RUNWAY SAFETY: A Best Practices Guide
to Operations and Communications
“Do not acknowledge the ATC instructions or clearances
by using your call sign and saying “Roger” or “Wilco” –
Instead read back the entire instruction or clearance
including the runway designator and aircraft call sign.”
Managing Human Errors
Blame the person
(Traditional approach)
AKA “Naming, blaming & shaming”
Systems Approach
Assume faulty system design
Errors seen as caused by
individuals
Carelessness
Inattention
Poor motivation
Forgetfulness
Poor training
Errors seen as upstream
system process design flaws
Look for weak links
Add barriers to reduce
chance of human error
Accepts fact that one cannot
change the human condition
Traditional approach has
and will continue to fail to
reduce human errors
"Insanity: doing the same
thing over and over again
and expecting different
results.” Albert Einstein
Work in collaborative
multidisciplinary teams
Analyze the process
Determine weak links
Determine bottlenecks
Determine high risk areas
Reduces errors & can lead
to sustained change
Strong support & hard work
can lead to a
change in culture
Culture of Safety >>>>>
Just Culture
Management strategy
Write more policies
Poster campaigns
Disciplinary actions
Re-train
Fire the individual
Support multidisciplinary
teams
Teach human error theory
Teach systems approach
Change the conditions under
which humans work
Design strategies/defenses
to avoid/avert errors or
mitigate their impact
Medical care: very complex chain of processes
Aim to improve patients’ health and well being
Each link in chain can be associated with
No problem
Intermittent problems
Variation
Near misses (recognized or not recognized)
Safe throughput requires
Knowing where the weak links, high risk areas and
dangers are
Having systems’ barriers that reduce likelihood of errors
Healthcare is more complex than any other industry
Overwhelming ongoing increase in knowledge
Technology increasing in complexity
Procedures increasingly more complex
Less continuity of care in hospitals; multiple teams deliver care
More handoffs: each handoff increases likelihood of error
Multi-tasking
Interruption-driven environment
Increasingly older, high acuity patients with little reserve
Pressure to perform more, faster and with less support
One person providing care for multiple patients
Errors occur more commonly
When clinicians are inexperienced
New procedures are introduced
Patients at extremes of age—(perhaps not more
errors, just less resilient )
Patients requiring complex care
Prolonged hospital stays
Highly technical areas, i.e., OR, ICU, ER
In highly technical surgical procedures, i.e., cardiac
surgery, neurosurgery, robotic surgery
You Don’t Have to Reinvent the Wheel
Much work already done
Start with already identified error prone areas
Medication
Surgery
ICUs
Handoffs
Research: lots of data about how to begin
Checklists
Computerized forcing functions
Computerized physician order entry
Team developed protocols
How might we apply error reducing principles to
an often overlooked but deadly problem
In-Hospital Cardiopulmonary Arrests (IHCA)
Specifically addressing a huge subset of IHCA
Postoperative Opioid Induced Respiratory Depression
In-Hospital Cardiopulmonary Arrests
(IHCA)
Up to 750,000 cardiopulmonary arrests annually in US hospitals
~ 80% of arrest victims do not survive to discharge
Studies show ~ 50% of those patients had been given opioids
Opioid induced respiratory depression
insidious
hard to diagnose using current technology
can lead to death or anoxic brain injury
occurs in very healthy patients
Consider: The Subset
Post-operative Opioid-Induced Respiratory Depression (POIRD)
3rd most common in-patient safety related error
>50 % postoperative respiratory events thought to be caused by opioids
Each institution’s incidence may seem low--- BUT--- that is misleading
~48 million in-patient procedures in US
Absolute number of POIRD events is significant
Unexpected death or brain injury can occur in even healthiest patients
Worse outcomes for respiratory events that occur on general nursing floor
Likely related to intermittent monitoring
Undetected respiratory compromise
Additional IV opioids +/- sedatives
No significant change in patient outcome in past 40 years
POIRD
2011
Our goal: “No Patient Shall Be Harmed By
Opioid-Induced Respiratory Depression”
Dr. Stoelting, President
Anesthesia Patient Safety Foundation (APSF)
2015
Anesthesiology, Closed Claims Analysis: POIRD
Conclusion:
Multifactorial
88% occur within first 24 hours of surgery
Most events are preventable with improvements in
Assessment of sedation/consciousness level
Monitoring of oxygenation
Monitoring of ventilation
Early response & intervention
Closed Claims Analysis
March 2015 Anesthesiology Lee, Caplan
Medication % Claims
factors
Peripheral nerve
blocks
0
Opioid given via
> 1 modality
50%
Continuous
opioid infusion
50%
Opioids +
concurrent nonopioid sedating
drug
33%
Multiple
physicians
ordering opioids
+/- sedating drugs
33%
%Claims
Timing of event
% Claims
Monitoring at time
of event
88%
Within 24 hours of
surgery
50%
No respiratory
monitors
13%
Within 2 hours of
D/C from PACU
33%
Non-telemetric
SPO2
Excessive doses rarely the cause
Example:
Tragic Error from 2015 Closed Claims Analysis
1st postop day: Obese, otherwise healthy 46 year old male
Described as sleepy, slow to arouse, snoring loudly
SPO2 read 49% on room air
oxygen cannula replaced, SPO2 soon 93%
Described as being without complaints
24 minutes later found apneic
Full code called
Died few days later with anoxic brain injury
We Cannot Continue As Usual
Large numbers of patients are still being harmed by postoperative opioids
POIRD often leads to death or anoxic brain injury
No change in patients’ outcomes for past 40 years
Monitoring SPO2 on general nursing floors is intermittent, if done at all
Monitoring respiratory rate alone is not adequate
Clinicians should be made aware
SPO2 is a monitor of oxygenation not ventilation
SPO2 can be misleading when a patient is on supplemental oxygen
SPO2 monitors are known to have significant number of false alarms
ETCO2 is misleading and inadequate in non-intubated patients
Respiratory rate does not detect inadequate ventilation
Monitoring ventilation
Tidal volume, minute ventilation and respiratory rate would be ideal
What Safety Lessons Can Be Learned from the
Closed Claims Analysis Data
Patients on opioids post operatively are high risk for POIRD

Continuously monitor oxygenation and ventilation
via telemetry or direct nurse call system

Use non-opioids analgesia when possible
peripheral nerve blocks
acetaminophen
ketorolac

Develop protocols that
 Provide oversight by one physician-led team
 With same goals & knowledge of patient
 For ordering opioids
 For ordering sedating drugs
 Do not allow opioids by more than one route
 i.e., if using PCA, do not give additional opioid IV push
Reducing Errors in Medicine
Requires Engaged Physicians
Leaders, Champions, and Supporters
“Shake Up” the status quo
Look at the data
Understand human error theory
Understand your system processes
Work in collaborative, multidisciplinary teams
administration, nursing, physician, quality, etc.
Help develop & support processes, protocols that drive safety
“Walk the Talk”, i.e., do what you ask others to do
Physicians have the power to lead, change, and sustain a
Culture of Safety
Culture of Safety Implies a
Just Culture
Just Culture-------Trust is essential component
Collective understanding of where the line should be
drawn between blameless and blameworthy actions.
Accepts that
< 10% of errors are culpable
> 90% of errors are systems’ flaws
 Can be reported without concern for reprisal or sanctions
Reduces fear in reporting
Allows learning from errors, near misses
Provides data to improve processes

Data and Data Analysis
Gather data about incidents and near-misses
Gather data about all cardiopulmonary arrests
Categorize & manage harm with severity assessment systems
Conduct Root Cause Analysis (RCA) to find sources of errors
Create opportunities for learning from errors and near misses
Establish Clinical Pathways, (evidence-based, standardized
patient management)
Establish protocols for high risk situations
Building a Safe Environment
Accept as a given:
One cannot change the human predisposition to make errors
Know the possibilities:
One can change the conditions under which humans work and
reduce errors in the delivery of healthcare
It is Also About You, Me, and
Those We Love
The urgency to decrease errors in healthcare should
be readily recognized by anyone who:
is likely to require care sometime in the future
is aging
or both
That anyone is each one of us & our loved ones
Reducing Medical Errors
A Marathon, Not a Sprint
24 hrs./day X 7 days/week X 52 weeks/year
References
1) Kohn, Corrigan, etal, eds, To Err is Human: Building a Safer Health System, Washington, DC: National Academy Press;
1999.
2) Am J Health Syst Pharm. 1997 Mar 1; 54(5):554-8
3) James; Evidence-based estimate of patient harm, In US hospitals, J Patient Safety 2013; 9: 122-128
4) Reason, JT , 1990 Cambridge, England:, Cambridge University Press
5) Anesthesiology 2010 POIRD6) Lee, Caplan, 2015 Anesthesiology, Postoperative Opioid-Induced Respiratory Depression, Closed Claims Analysis
7) Fecho K, Jackson F, Smith F, Overdyk FJ. In-hospital resuscitation: opioids and other factors influencing survival.
Ther Clin Risk Manag. 2009;5:961-968.
8) Brady WJ, Gurka KK, Mehring B, Peberdy MA, O’Connor RE; American Heart Associations’ Get with the Guidelines
(formerly, NRCPR) Investigators. In-hospital cardiac arrest: impact of monitoring and witnessed event on patient survival
and neurologic status at hospital discharge. Resuscitation. 2011;82(7):845-852.
9) HealthGrades. The Sixth Annual HealthGrades Patient Safety in American Hospitals Study.
http://www.healthgrades.com/business/img/PatientSafetyInAmericanHospitalsStudy 2009.pdf. Accessed August 22, 2012.
10) Overdyk FJ. Postoperative opioids remain a serious patient safety threat. Anesthesiology. 2010;113(1):259-260.
11) Peberdy MA, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA.
2008; 299(7):785-792.
12) HodgettsTJ,KenwardG,Vlackonikolis,I , etal .Incidence,location and reasons for avoidable in-hospital arrest in a
district general hospital. Resuscitation. 2002;54(2):115-123.