Transcript Slide 1

Safeguarding Patients from
Medical Errors
Dawn Berndt, MS, RN, CRNI
Clinical Nurse Specialist – Infusion
University of Wisconsin Hospital and Clinics
Madison, Wisconsin
Dallas, TX • November 2–4, 2012
Objectives
• Explore the causality of medical errors
• List the types of errors
• Methods the infusion nurse can use in
limiting errors
Dallas, TX • November 2–4, 2012
Medical Error Statistics
The Institute of Medicine reports:
• Medical Errors
– 98,000 Americans die every year from a
preventable medical error.
– Cost of medical errors is about $29 billion
annually.
• Medication errors (most common medical error)
– 1.5 million people harmed annually
– 7000 deaths annually
– Cost more than $3.5 billion annually (hospitals)
Dallas, TX • November 2–4, 2012
Costly Frequent Medical Errors
Type of Medical Error
1. Pressure ulcers
2. Postoperative infections
3. Mechanical complication of a device,
implant or graft
4. Postlaminectomy syndrome
5. Hemorrhage complicating a procedure
6. Infection following infusion, injection,
transfusion, vaccination
7. Pneumothorax
8. Infection due to central venous catheter
9. Other complications of internal prosthetic
device, implant and graft
10. Ventral hernia without mention of
obstruction or gangrene
Number Cost per
of Errors Error
Total Cost
374,964
$10,288
$3.858 billion
252,695
$14,548
$3.676 billion
60,380
$18,771
$1.133 billion
113,823
$9,863
$1.123 billion
78,216
$12,272
$960 million
8,855
$78,083
$691 million
25,559
$24,132
$617 million
7,062
$83,365
$589 million
26,783
$17,23
$462 million
53,810
$8,178
$440 million
Definitions
Medical Error (Reference MD):
Errors or mistakes committed by health
professionals which result in harm to the
patient. They include errors in diagnosis,
errors in the administration of drugs and
other medications.
Medical Error (IOM):
The failure of a planned action to be
completed as intended or… the use of a
wrong plan to achieve an aim.
Dallas, TX • November 2–4, 2012
Definitions
Medication Error (National Coordinating Council
for Medication Error Reporting and Prevention) :
“Any preventable event that may cause or
lead to inappropriate medication use or
patient harm while the medication is in
the control of the health care
professional, patient, or consumer….”
Dallas, TX • November 2–4, 2012
Types of Errors
• Active Errors occur at the point of contact
between a human and some aspect of a
larger system.
• Sometimes referred to as the “sharp end”
where practitioners are in direct contact
with the critical safety processes.
– Example: Programming an infusion pump
incorrectly.
Dallas, TX • November 2–4, 2012
Types of Errors
• Latent Errors refer to less obvious failures
of an organization or system that
contribute to the occurrence of errors.
• Sometimes referred to as the “blunt end”
referring to the multiple layers of safety
management that affect the person at the
sharp end.
– Example: the organization has 10 types of
pumps
Dallas, TX • November 2–4, 2012
Where Medication Errors
Occur
• 39% Ordering Process
• 12% Transcription
• 11% Pharmacy preparation
• 38% Administration
Sharp end of the
stick
Dallas, TX • November 2–4, 2012
Why Do Errors Occur?
The Institute of Medicine states:
“… the problem in medical errors is not
bad people in health care—it is that
good people are working in bad
systems that need to be made safer.”
Dallas, TX • November 2–4, 2012
Dallas, TX • November 2–4, 2012
Why Do Errors Occur ?
The Joint Commission's Annual Report on
Quality and Safety 2007 identified these
points:
• Inadequate communication between
healthcare providers, or between providers
and the patient and family members
• Inadequate assessment of the patient's
condition
• Poor leadership
• Poor training
Dallas, TX • November 2–4, 2012
Human Factors that
Contribute to Errors
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Fatigue
Time pressures
Unfamiliar with care setting
Unfamiliar with technology
Diverse patient populations
Patient to nurse staffing ratios
Dallas, TX • November 2–4, 2012
System Designs that
Contribute to Errors
• Poor organizational communication
practices
• Relying on automated systems to prevent
errors
• No system to share error information limits ability to analyze causes and plan
improvement strategies
• Poor environmental designs
• Wrong assumptions - action is being taken
by someone else within the institution
Dallas, TX • November 2–4, 2012
Normalization of Deviance
Quote from Culture of Safety (Duke University
Medical Center):
“System flaws set up good people to fail. 80%
of errors are system induced. People often find
ways of getting around processes which seem
to be unnecessary or which impede the
workflow. This is known as normalization of
deviance.
Dallas, TX • November 2–4, 2012
Normalization of Deviance
• Myth: Major harm-causing errors are the
result of a single individual making one
very wrong choice.
• Truth: Major harm-causing errors involve:
1. Multiple people
2. Committing seemingly innocuous mistakes
3. These mistakes breech organizational safety
systems or fail-safe mechanisms
4. Eventually result in a serious event
Dallas, TX • November 2–4, 2012
Normalization of Deviance
• Example: Discouraging Drug Diversion in
NICU
– RN must enter password to remove
medication from ADC
– Second RN was required to enter
password for wasting remainder of
medication
– RNs resent having to bother one another
– RNs shared passwords to bypass system
Dallas, TX • November 2–4, 2012
Why Do Errors Occur ?
Why do intelligent, conscientious and
methodical professionals fail to see
what should be obvious?
Dallas, TX • November 2–4, 2012
Why Do Errors Occur ?
Inattentional Blindness
• Also known as perceptual blindness is the
failure to see an object because our attention
is not focused on it.
• The phenomenon is due to how our minds
see and process information.
• Recent evidence shows that it is much more
pervasive than previously understood and
that it is one of the major causes of accidents
and human error.
Dallas, TX • November 2–4, 2012
Why Do Errors Occur?
• All persons are inattentionally blind to most
things … all of the time … every day.
• An individual performing a task just fails to
see what should have been plainly visible.
Afterwards, the person cannot explain why
he/she did not see it.
• Often, the individual making the error is
likely to be considered negligent.
Dallas, TX • November 2–4, 2012
Why Do Errors Occur ?
• “Inattentional blindness: What captures
your attention?”
– Conspicuity
– Mental workload and task interference
– Expectation
– Capacity
Dallas, TX • November 2–4, 2012
Effects of Interruptions
on Medical Errors
Interruption/distraction:
An interruption is an event initiated by another
person(s) or something else such as a call
light or pager as well as instances when a RN
interrupts himself/herself.
Dallas, TX • November 2–4, 2012
Effects of Interruptions
on Medical Errors
• Multitasking is defined as being involved in
two or more overlapping tasks at one time.
• A break in task is when the RN stops what
he/she is doing for more than 10 seconds.
Dallas, TX • November 2–4, 2012
Effects of Interruptions
on Medical Errors
A growing body of evidence suggests that
interruptions to nurses’ work may be a
significant cause for medication errors.
• When individuals are
interrupted,
information is lost.
• Multitasking creates a
higher memory load.
Both
predispose
individuals to
make errors.
Dallas, TX • November 2–4, 2012
Effects of Interruptions
on Medical Errors
• Interruptions negatively affect an
individual’s working memory, which is
limited in its capacity and transient in
nature.
– When interrupted, individuals lose their
train of thought.
– Once lost, individuals may not regain the
thought process.
Dallas, TX • November 2–4, 2012
Effects of Interruptions
on Medical Errors
Dallas, TX • November 2–4, 2012
Culture of Interruption
Are you “connected” when you shouldn’t be?
Dallas, TX • November 2–4, 2012
Aviation Industry Prohibits
Interruptions
• Other high-risk industries have clearly identified
the significance of work interruptions and their
potential contribution to human errors.
• Sterile cockpit
• In 1981, the Federal Aviation Administration
(FAA) addressed this issue by making policies
that prohibited interruptive interactions or
behavior during “high threat” times such as taxi,
takeoff or landing.
• Healthcare has not enacted similar policies.
Dallas, TX • November 2–4, 2012
Case Study
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Sentinel event
July 6, 2006
440 bed hospital
Madison, Wisconsin
Dallas, TX • November 2–4, 2012
Case Study
• Very experienced nurse working in labor and
delivery
• The nurse was fatigued
• Worked for two consecutive eight-hour shifts
the day before
• Slept in the hospital before coming on duty
the following morning
• Had another patient with probable delivery of
a nonviable fetus
• New patient - 16 y/o who arrived 3 hours late
for induction
Dallas, TX • November 2–4, 2012
Case Study
• Patient appeared very anxious, asking many
questions
• Nurse was trying to answer the patient’s
questions and calm her fears while prepping
her for delivery
• Spent 2 hours with patient and family
exploring family dynamics
• Admission was completed, but bar-coded ID
band was not placed on the patient
Dallas, TX • November 2–4, 2012
Case Study
• Patient indicated the desire to have
epidural pain management during labor
• 1130: membranes were ruptured by
physician – discussed use of epidural
• Nurse left room to obtain fluid, pitocin,
delivery kit medications and epidural
medication
• When walking back to the patient’s room,
another RN handed her a bag of penicillin for
the patient’s strep infection
Dallas, TX • November 2–4, 2012
Case Study
• The patient’s boyfriend (baby’s father)
arrived; there was tension between him and
the patient’s mother
• To help diffuse tension, the nurse decided to
show an educational video as soon as she
started the patient’s IV and penicillin dose
• The nurse programmed the infusion pump
and started an intravenous infusion
Dallas, TX • November 2–4, 2012
Case Study
• The RN did not scan the medication
because she planned to scan it and
document after starting the video
• Within minutes, the patient exhibited
seizure-like activity, respiratory distress,
then cardiac collapse
• The RN stopped the infusion suspecting a
reaction to penicillin
• Providers attempted resuscitation; patient
did not respond
Dallas, TX • November 2–4, 2012
Case Study
• The patient was moved to OR
• Healthy infant was delivered by
emergency C-section
• Resuscitating work continued for 80
minutes
• Eventually providers noticed that the
epidural medication was infused
intravenously instead of the antibiotic
Dallas, TX • November 2–4, 2012
Root Cause Analysis
1. At the time of the event, nurses were
responsible for retrieving epidural
medications from the ADC.
– The nature of care provided to patients in
labor makes it difficult for nurses to leave the
patient for medications or supplies.
– Accordingly, anticipated supplies, including
medications, were often brought into patients’
rooms ahead of time.
Dallas, TX • November 2–4, 2012
Root Cause Analysis
2. It was difficult to determine, if, before this
event, nurses at the hospital believed that
bringing an epidural medication to the
patient’s room before it was prescribed or
needed posed a serious risk.
– Anesthesia staff at the hospital had a history
of expressing dissatisfaction with patients’
state of readiness for the epidural.
– This dissatisfaction had put pressure on
nurses to ensure that the patient was ready for
an epidural before anesthesia staff arrived.
Dallas, TX • November 2–4, 2012
Root Cause Analysis
3. Historically, identification bands arrived on
the labor and delivery unit several hours
after admission.
– It was difficult for nurses to leave the room
to pick up the bracelet.
– It became normal that there was no
systematic application of identification
bands on the unit, demonstrating the
phenomenon of “normalization of
deviance.”
Dallas, TX • November 2–4, 2012
Root Cause Analysis
4. The POC bar-coding system was recently
implemented.
– The unit-wide compliance for utilizing the new
system was only 50%.
– Obstetrical unit staff had suboptimal training –
the RN involved had minimal experience with
using the system because of vacation during
the first week of implementation.
– The new system had work-flow and scanning
problems that caused some RNs to bypass
the POC bar-coding system.
Dallas, TX • November 2–4, 2012
Active Causes
– The epidural medication was brought into the
patient’s room before it was needed or
prescribed.
– The nurse picked up the wrong medication
(epidural), failed to read the label fully, and
prepared the medication for IV infusion
instead of the intended drug (IV penicillin).
– The nurse didn’t place an ID band on the
patient, which was required to utilize the barcoding system to match, the prescribed drug
therapy with the selected/drug.
– The nurse failed to use the bar-code system
before drug administration.
Dallas, TX • November 2–4, 2012
Case Study – RN’s Outcome
The nurse was charged criminally by
the Department of Justice for an
unintentional medication error.
Dallas, TX • November 2–4, 2012
Case Study – RN Outcome
• The ability to work as a nurse was
suspended for a period of 9 months
• After suspension, license was limited
• Must work no more than 12 hours in any
24 hour period; no more than 60 hours in
any 7 consecutive days
Dallas, TX • November 2–4, 2012
Case Study – RN Outcome
• Must complete an approved educational program
or programs, which total 54 hours (equivalent to
3 academic credits), and which address the roles
of individuals and systems in preventing
medication and health care errors.
• Must give 3 presentations to nursing community.
• Pay to the Department of Regulation and
Licensing costs of this proceeding in the amount
of $2,500 pursuant to Wis. Stat. § 440.22(2).
Dallas, TX • November 2–4, 2012
Case Study
Aftermath
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Wisconsin Nurses Association
Two bills were introduced to the Wisconsin State
Legislature in January – SS-SB1 & SS-AB1
─ Omnibus in nature
─ Focused on tort reform
─ One included language for decriminalization for
unintentional medical errors
─ Amended State Statute 940.295(3) which provides
exemption for criminal liability for health care providers
acting with in the scope of practice ; acting in good
faith, but causes harm to a patient.
Dallas, TX • November 2–4, 2012
Decriminalization of
Unintentional Medical Error
• The bill modifies the state's criminal code to
avoid the criminalization of unintentional
human error that may occur in the medical
setting.
• The change was made to assure that
unintentional medical errors will be a matter
for civil, not criminal, courts.
Dallas, TX • November 2–4, 2012
How are errors prevented?
And
What can infusion nurses do?
Dallas, TX • November 2–4, 2012
Preventing Medical Errors
Organizationally
• Follow the Joint Commission’s National
Patient Safety Goals
– Identify patients correctly
– Improve staff communication
– Use medicines safely
– Prevent infection
– Check patient medicines
– Identify patient safety risks
Dallas, TX • November 2–4, 2012
Preventing Medical Errors
Organizationally
• Utilize organizational systems for
voluntary error reporting
– Learn from errors
– Learn from good catches
– Discover trends
– Track problems with equipment or
processes
Dallas, TX • November 2–4, 2012
Preventing Medical Errors
Organizationally
• Key Components of an Effective Event
Reporting System (Agency for Healthcare Research and
Quality):
– Institution must have a supportive environment
for event reporting that protects the privacy of
staff who report occurrences.
– Reports should be received from a broad range of
personnel.
– Summaries of reported events must be
disseminated in a timely fashion.
– A structured mechanism must be in place for
reviewing reports and developing action plans.
Dallas, TX • November 2–4, 2012
How do Infusion Nurses
Prevent Medical Errors?
• Five medication rights (or more)
• Safe patient hand-offs
• Double checking – second nurse
verification
• Technology – scan barcodes, safety
software for infusion pumps
• Medication reconciliation
Dallas, TX • November 2–4, 2012
How do Infusion Nurses
Prevent Medical Errors?
Own our attitudes and behaviors related to:
– Policies
– Shortcuts or work-arounds
– Preceptors influence
– Accountability
Dallas, TX • November 2–4, 2012
How do Infusion Nurses
Prevent Medical Errors?
• Work toward change
– Change the interruption-laden culture of
your health care organization.
– Plan environmental design improvements
for work spaces to facilitate no-interruption
zones in medication preparation areas.
– Make policies regarding the use of
personal electronic devices.
Dallas, TX • November 2–4, 2012
Dallas, TX • November 2–4, 2012
Online Safety Resources
• http://www.kaiseredu.org/IssueModules/Reducing-Medical-Errors/KeyOrganizations.aspx
• Agency for Healthcare Research and Quality
• Institute for Healthcare Improvement
• Joint Commission on the Accreditation of
Healthcare Organizations
• Leapfrog Group
• http://www.ismp.org/
Dallas, TX • November 2–4, 2012
References
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Dallas, TX • November 2–4, 2012
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121.542.htm