Transcript Reducing medical error and increasing patient safety

Reducing medical error and
increasing patient safety
Richard Smith
Editor, BMJ
What I want to talk about
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A story
How common is error?
Why does error happen?
How should we think of error?
How should we respond?
A story
How common is error?
• Harvard Medical Practice Study
• Reviewed medical charts of 30 121 patients
admitted to 51 acute care hospitals in New
York state in 1984
• In 3.7% an adverse event led to prolonged
admission or produced disability at the time
of discharge
• 69% of injuries were caused by errors
How common is medical error?
• Australian study
• Investigators reviewed the medical records of
14 179 admissions to 28 hospitals in New
South Wales and South Australia in 1995.
• An adverse event occurred in 16.6% of
admissions, resulting in permanent disability in
13.7% of patients and death in 4.9%
• 51% of adverse events were considered to have
been preventable.
How common is medical error?
• The differences between the US and
Australian results may reflect different
methods or different rates
• Other, smaller studies (including one from
Britain) show similar orders of errors
• There are few studies from outpatients or
primary care
How common is medical error?
• An evaluation of complications associated
with medications among patients at 11
primary care sites in Boston.
• Of 2258 patients who had had drugs
prescribed, 18% reported having had a drug
related complication, such as
gastrointestinal symptoms, sleep
disturbance, or fatigue in the previous year.
Results of medical error
• In Australia medical error results in as many
as 18 000 unnecessary deaths, and more
than 50 000 patients become disabled each
year.
• In the United States medical error results in
at least 44 000 (and perhaps as many as 98
000) unnecessary deaths each year and 1
000 000 excess injuries.
Types of error
• About half of the adverse events occurring
among inpatients resulted from surgery.
• Next come
– Complications from drug treatment
– therapeutic mishaps
– diagnostic errors were the most common nonoperative events. In the Australian study
cognitive errors, such as making an
Types of error
• Cognitive errors--such as incorrect
diagnosis or choosing the wrong
medication-- more likely to have been
preventable and more likely to result in
permanent disability than technical errors.
Which patients are most at risk?
• Those undergoing cardiothoracic surgery,
vascular surgery, or neurosurgery
• Those with complex conditions
• Those in the emergency room
• Those looked after by inexperienced doctors
• Older patients
How dangerous is health care?
• Less than one death per 100 000 encounters
– Nuclear power
– European railroads
– Scheduled airlines
• One death in less than 100 000 but more than 1000 encounters
– Driving
– Chemical manufacturing
• More than one death per 1000 encounters
– Bungee jumping
– Mountain climbing
– Health care
Why do errors happen?
• All humans make errors: indeed, “the ability
to make mistakes” allows human beings to
function
• Most of medicine is complex and uncertain
• Most errors result from “the system”-inadequate training, long hours, ampoules
that look the same, lack of checks, etc
• Healthcare has not tried to make itself safe
How to think of error?
• An individual failing
– Only the minority of cases amount from negligence
or misconduct; so it’s the “wrong” diagnosis
– It will not solve the problem--it will probably in
fact make it worse because it fails to address the
problem
– Doctors will hide errors
– May destroy many doctors inadvertently (the
second victim)
How to think of error?
• A systems failure
– This is the starting point for redesigning the
system and reducing error
How to respond? Tactics
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Reduce complexity
Optimise information processing
– checklists, reminders, protocols
• Automate wisely
• Use constraints
– for instance, with needle connections
• Mitigate the unwanted side effects of change
– with training, for example.
Building a safe healthcare
system (from James Reason)
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Principles
Policies
Procedures
Practices
Building a safe healthcare
system (from James Reason)
• Principles
– Safety is everybody’s business
– Top management accepts setbacks and
anticipates errors
– safety issues are considered regularly at the
highest level
– Past events are reviewed and changes
implemented
Building a safe healthcare
system (from James Reason)
• Principles
– After a mishap management concentrates on
fixing the system not blaming the individual
– Understand that effective risk management
depends on the collection, analysis, and
dissemination of data
– Top management is proactive in improving
safety--seeks out error traps, eliminates error
producing factors, brainstorms new scenarios of
failure
Building a safe healthcare
system (from James Reason)
• Policies
– Safety related information has direct access to
the top
– Risk management is not an oubliette
– Meetings on safety are attended by staff from
many levels and departments
– Messengers are rewarded not shot
– Top managers create a reporting culture and a
just culture
Building a safe healthcare
system (from James Reason)
• Policies
– Reporting includes qualified indemnity,
confidentiality, separation of data collection
from disciplinary procedures
– Disciplinary systems agree the difference
between acceptable and unacceptable behaviour
and involve peers
Building a safe healthcare
system (from James Reason)
• Procedures
– -Training in the recognition and recovery of
errors
– Feedback on recurrent error patterns
– An awareness that procedures cannot cover all
circumstances; on the spot training
– Protocols written with those doing the job
– Procedures must be intelligible, workable,
available
Building a safe healthcare
system (from James Reason)
• Procedures
– Clinical supervisors train their charges in the
mental as well as the technical skills necessary
for safe and effective performance
Building a safe healthcare
system (from James Reason)
• Practices
– Rapid, useful, and intelligible feedback on
lessons learnt and actions needed
– Bottom up information listened to and acted on
– And when mishaps occur
• Acknowledge responsibility
• Apologise
• Convince patients and victims that lessons learned
will reduce chance of recurrence
James Reason’s bottom line
• Fallibility is part of the human
condition
• We can’t change the human
condition
• We can change the conditions
under which people work
Conclusions
• Human beings will always make errors
• Errors are common in medicine, killing tens
of thousands
• We begin to know something about the
epidemiology of error, but we need to know
much more
• Naming, blaming and shaming have no
remedial value
Conclusions
• We need to design health care systems that
put safety first (First, do no harm)
• We know a lot about how to do that
• It’s a long, never ending job