Transcript Health Access Deprivation Index:

The Epidemiology of
Patient Safety and
Medical Error
WVU Department of Family Medicine
RCB HSC-Eastern Division
Konrad C. Nau, MD
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“Man's heart stops after Bettis
fumble” – Pittsburgh Tribune
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“Man goes into cardiac arrest at
Cupka's bar, in the South Side”
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“Man's heart stops after Bettis
fumble” – Pittsburgh Tribune
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“Man's heart stops after Bettis
fumble” – Pittsburgh Tribune
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“I made a mistake. It’s my job to
protect the ball – Jerome Bettis
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Why all this fuss about
Patient Safety ?
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Prevalence
• Average of 1.7 mistakes per patient per day in
ICU (out of 200 patient-care activities)
• 1% failure rate is too high to be tolerated
• At 99.9%, there would be two unsafe plane
landings at O’Hare airport each day, U.S. postoffice would lose 16,000 pieces of mail, and
32,000 bank checks would be deducted from
wrong accounts every hour
— From Lucien Leape
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Aviation Model : Error Happens
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Aviation Model : Error Happens
• 1903
First Powered Flight
• 1908
First Pilot dies
• 1910
First mid-air collision
• 1918
31 of first 40 US Air Mail pilots
die in crashes
• 1994
4 crashes/10,000,000 takeoffs
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Patient Safety
• The avoidance, prevention and amelioration of
adverse outcomes or injuries stemming from the
processes of health care.
• These events include "errors," "deviations," and
"accidents."
• Safety emerges from the interaction of the
components of the system; it does not reside in
a person, device or department.
(Cooper, et al)
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Patient Safety
• Freedom from accidental injury
• establishment of operational systems and
processes that
– minimize the likelihood of errors
– maximize the likelihood of intercepting them when
they occur.
(Kohn)
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Patient Safety
• actions undertaken by
– individuals
– organizations
• to protect health care recipients from being
harmed by the effects of health care services.
(Spath)
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Patient Safety Vocabulary
• Adverse Event
– Injury the results from medical care
• Preventable Adverse Event
– Error, could/should not have happened
• Non-Preventable Adverse Event
– Could not have been predicted or foreseen
• Potential Adverse Event
– “Near miss” or “close call”
– No harm done…error intercepted
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Patient Safety Vocabulary
• Error
– the failure of a planned action to be completed as
intended
– the use of a wrong plan to achieve an aim.
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Medical Error
Medical Errors
Any error in the health
care delivery process
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Adverse Event
AE
Injury that results
from medical care,
not a part of the natural disease process
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Adverse Events
Non-preventable
Adverse Events
AE
Medical Errors
Preventable
Adverse Events
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Near Miss
Near MissPotential Medical Error
Intercepted error
Medical Errors
Near
Miss
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Medical Errors & Adverse Events
Non-preventable
Medical Errors
AE
Near
Miss
Preventable AE
Serious Medical Errors
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A Generic Model of Safety
Defenses
DANGER
Hazards
Potential
Adverse Event
Defenses can be hardware (e.g., monitors), people (e.g., nurses)
or administrative (e.g., acceptable protocols)
(From Managing the Risks of Organizational Accidents, Reason, 1997)
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A Near Miss
Defenses
DANGER
Hazards
Potential
Adverse Event
Usually several defenses must fail to cause an accident—
Just one remaining intact is enough to prevent a near-miss
becoming an accident…
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A Harmful Event
Defenses
DANGER
Hazards
Adverse
Event
What is “the cause”? The hazard? Failure of which defense?
This is the problem with assigning single causes…
Blame/cause often is assigned to the last barrier [usually a
person] to fail!!
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Observed Path to Schedule and
Complete a Doctor’s Appointment
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Quality and
Error
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To Err is Human
• Process
• People
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To Err is Human
• Process ………85%
• People………..15%
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Errors are Treasures
• Every process is perfectly designed to achieve
exactly the results it gets.
• As long as we keep on doing what we keep on
doing, we’ll keep on getting what we’ve got .
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The Swiss Cheese
Model of Safety
Layers of Protection
Some holes due
to active failures
Adverse
Event
Hazards
Other holes due to
latent conditions
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When all the holes lined up
Elevated
PT INR
Lab tech
Result to office nurse
Patient Falls –
Cerebral Hemorrhage
Physician interprets
Patient contacted
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Errors
• “Most organizational errors are made by
well-intentioned human beings—most
highly educated, well trained, well
intentioned human beings—who become
accustomed to small glitches, routine foulups, and a culture that suppresses doing
much about them in the name of an
overriding goal.”
• James Reason – Internal Bleeding
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Latent Errors
• Latent errors = process or system failures
• Pose the greatest threat to safety in a complex system
because
• Lead to operator errors.
• They are failures built into the system and present long
before the active error.
• Latent errors are difficult for the people working in the
system to see since they may be hidden in computers or
layers of management
• people become accustomed to working around the
problem
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Six Changes That
Save Hospital Patient Lives
•
•
•
•
•
•
Deployment of Rapid Response Teams…at the first sign of
patient decline
Delivery of Reliable, Evidence-Based Care for Acute
Myocardial Infarction…to prevent deaths from heart attack
Prevention of Adverse Drug Events (ADEs)…by implementing
medication reconciliation
Prevention of Central Line Infections…by implementing a
series of interdependent, scientifically grounded steps called the
“Central Line Bundle”
Prevention of Surgical Site Infections…by reliably delivering
the correct perioperative antibiotics at the proper time
Prevention of Ventilator-Associated Pneumonia…by
implementing a series of interdependent, scientifically grounded
steps called the “Ventilator Bundle”
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Ambulatory Care is different
• Care is brief and episodic from the providers
point of view
• Patients and clinicians have many degrees of
freedom
• Feedback loops are long
• Adverse Events are often not directly seen or
even reported
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Learning from Different Lenses:
Reports of Medical Errors in Primary
Care by Clinicians, Staff and Patients
Robert Phillips
Deborah Graham
Nancy Elder
John Hickner
Susan Dovey
A Project of the AAFP National Research Network
Presented at the:
33rd NAPCRG Annual Meeting
October 15-18, 2005
Quebec City, Quebec, Canada
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Context
• Primary Care:
– ~½ a billion office visits annually
– the medical home for most Americans
– Malpractice claims = burden of serious harms and
death from medical errors is substantial
– Most studies of errors reported by physicians =
important but limited lens
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Setting
• 10 family physician offices:
– 5 private practices
– 5 residency clinics
• American Academy of Family Physician
(AAFP) National Research Network
• mix of rural, urban, and suburban, private and
community practices
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Asked to Report
• “That should not have happened and that you
don’t want to happen again”
• Small or large, administrative or clinical
• Could be events or processes that didn’t happen
but should have happened
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Results
• 401 physicians and staff signed a consent
form and/or participated in site training (86%
of eligible)
• Clinic physicians, NPs/PAs, residents, and
staff reported 726 events, 717 with errors
–
–
–
–
Staff 384 (53%)
physicians 278 (38%)
residents 46 (6%)
NPs and PAs 18 (3%)
• 935 total errors
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Top Ten Errors (AAFP NRN)
Error Codes
Chart completeness and availability
Medications
Appointments
Filing system
Laboratory
Communication with patients
Patient flow
Communication healthcare team
Message handling
Diagnostic imaging
Total Physicians Staff
177 (19%)
76 (18%) 101 (20%)
127 (14%) 70 (16%) 57 (11%)
111 (12%)
40 (9%) 71 (14%)
84 (9%)
37 (9%) 47 (9%)
82 (9%) 47 (11%) 35 (7%)
65 (7%)
19 (4%) 46 (9%)
55 (6%)
22 (5%) 33 (7%)
34 (4%)
20 (5%) 14 (3%)
33 (4%)
14 (3%) 19 (4%)
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25 (3%)
16 (4%)
9 (2%)
Error Consequences (AAFP NRN)
Money/Time consequence
Care Consequence
Health Consequence
Unknown
No Consequence
0%
10%
20%
30%
40%
50%
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Error Consequences (AAFP NRN)
Consequences
Discovered and resolved
error
Total
Codes
(N=1119)
Codes:
Physician
(N=545)
Codes:
Staff
(N=574)
175 16%
66
12%
109
19%
104
9%
62
11%
42
7%
Nurse/Staff time
94
8%
17
3%
77
13%
Patient time
94
8%
37
7%
57
10%
Delay in receiving care
63
6%
37
7%
26
5%
Patient upset or anxious
Physician time
58
45
5%
4%
21
35
4%
6%
37
10
6%
2%
37
3%
20
4%
17
3%
27
21
2%
2%
64%
14
18
3%
3%
60%
13
3
2%
1%
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68%
Patient put at heightened
risk of bad outcome
Lost/missing patient
information
Delay in starting
(appropriate) treatment
Sub-optimal care
Patient reports (AAFP NRN)
• 6 reports of extended waiting
• 2 reports of mistaken identity
• 1 report each
–
–
–
–
–
–
–
–
unnecessary blood-draw
Prescriptions
poor vaccination documentation
unnecessary emergency room visits (unable to reach PCP)
inability to get laboratory tests due to lack of insurance
inappropriate comments by clinicians
clinician-induced fear (patient left without treatment)
credit card theft
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Clinician and Staff reports
(AAFP NRN)
• 96% were process errors
• Clinicians were significantly more likely to report
– errors related to medications, laboratory
investigations, and diagnostic imaging
• Staff were significantly more likely to report
– communication with patients and appointments.
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Multiple errors
• Multiple errors:
– 4 reports contained four errors
– 33 reports contained three errors
– 183 cases two errors
• 93 cascades
– Chart completeness and availability; medications;
appointments; laboratory; patient flow; and filing
systems.
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Consequences & harms
• 706 reports had consequences or harms
– No patient died
– 3 patients required urgent care, were admitted to
a hospital, or had to visit the emergency room
– 4 patients suffered pain or injury
– 10 patients’ health condition worsened
– Most placed the patient at heightened risk of
harm (49%), or made the patients, their families
or their health clinicians upset (33%).
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Seriousness
• “Complex” patients more likely very/extremely
serious harm (31% vs. 20%, p=0.013)
• No difference in risk for patients with chronic
conditions (29% vs. 21%, p=0.086)
• No differences for patients familiar vs. unfamiliar
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AAFP NRN Discussion
• Chaotic busy days, healthcare team
communication failures, and breakdowns in
protocols or guidelines often leave patients
vulnerable
• “Complex” patients should raise concern of
serious harms
• Reporters have difficulty divorcing systematic
errors from blame
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AAFP NRN Discussion
• Multiple errors and error-cascades are common
• Patients either don’t see errors often, won’t
report them —understanding errors from their
perspective will require another approach
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The Improving Medication
Prescribing (IMP) Study
Patient survey of primary care
practices associated with a Boston
teaching hospital
Gandhi,TK. NEJM April 2004
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Adverse Drug Events reported in
25% of ambulatory patients (IMP)
Serious
15%
Non-serious
42%
Preventable
12%
Ameliorable
31%
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Ameliorable Adverse Drug Events
(IMP)
Patient failed to
inform
physician of
symptoms
57%
Physician failed
to act on patient
symptoms
43%
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IMP Prescription Review
• 1879 prescriptions reviewed
• Medication errors
143 8 %
• Potential ADE
62
3%
– Life threatening
1
2%
– Serious
15
24%
– Significant
46
74%
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Follow-up of Ambulatory
Diagnostic Tests
Tejal Ghandi, MD,MPH
Eric Poon, MD,MPH
Patient Safety
Brigham and Women’s Hospital
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Physician management of
ambulatory test results
• Typical full-time primary care physician
in ONE WEEK
– 820 lab results
– 40 diagnostic images
– 12 pathology reports
– Spends 72 minutes/day managing results
– 57 % are NOT SATISFIED with the way they
manage test results
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Physician management of
ambulatory test results
• 75% of physicians did not notify patients of
normal results
• 33% of physicians did not notify patients of
abnormal results
• 33% of women with abnormal mamograms or
PAP smears do not receive appropriate
follow-up care
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Physician management of
ambulatory test results
• Question: How many times in the past 2 months have you
reviewed test results you wish you had reviewed earlier ?
40%
35%
30%
25%
20%
15%
10%
5%
0%
0
(1-2)
(3-4)
(5-6)
(7-8)
(>8)
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Five Steps to Safer Health Care
• 1. Ask questions if you have doubts or
concerns.
• 2. Keep and bring a list of ALL the medicines
you take.
• 3. Get the results of any test or procedure.
• 4. Talk to your doctor about which hospital is
best for your health needs..
• 5. Make sure you understand what will
happen if you need surgery.
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SUMMARY
• Medical error and near-misses occur both in
hospital and ambulatory settings
• Medical error is typically the result of process
problems
• Patient Safety is the foundation for Quality
Medical Care
• For a clinic to be dedicated to QUALITY , we
must all be dedicated to Patient Safety
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