Transcript Why is this so hard? - National Association of Community Health

Patient Safety
Suzanne Graham, RN, PhD
SUB TITLE HERE
Let’s Talk
Objectives
• Describe the scope of error in healthcare
Describe the public and patient
perception of safety in healthcare
• Describe the scope of error in the
outpatient setting
• Discuss why improving safety in
healthcare has been difficult
Share Your Experience
Have you or someone you’ve known
experienced a medical error?
Have you or someone you’ve known
contributed to a medical error?
Why do we care?
The IOM Report
 44,000-98,000 patients die each year in hospitals
from medical error
 Up to 270 patients die each day in hospitals due
to error
 More people die each year from error than from
breast cancer, motor vehicle accidents and AIDS
How Do We Compare?
(Graph created by Lucien Leape)
DANGEROUS
(>1/1000)
100,000
REGULATED
ULTRA-SAFE
(<1/100K)
HealthCare
Total lives lost per year
Driving
10,000
1,000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
Chemical
Manufacturing
Chartered
Flights
European
Railroads
Nuclear
Power
1
1
10
100
1,000
10,000
100,000
Number of encounters for each fatality
1,000,000 10,000,000
Headlines & Errors
• State Faults Kaiser for Fatal Injection

Ulysses Torassa, San Francisco Chronicle (November 3, 2005)
• Kaiser Hospitals Implement Safeguards:
New Procedures at 2 Sites Where Fatal
Mistakes Occurred

Kathleen Sullivan, Chronicle Staff Writer (November 5, 2005)
• State Criticizes Kaiser Over Death
 Kathleen Sullivan, San Francisco Chronicle (November 10,
2005)
Headlines & Errors
• Medical Mistake May Have Killed Man
 Julie Sevrens Lyons, San Jose Mercury News (November 2, 2005)
• “Terrible Error”, Then a Death
 David L. Beck and Julie Sevrens Lyons, San Jose Mercury News
(November 3, 2005)
• Another Death in ’05 Attributed to Hospital
Error
 Julie Sevrens Lyons, San Jose Mercury News (November 4, 2005)
• Hospitals Blamed in More Deaths
 David L. Beck San Jose Mercury News (November 10, 2005)
Safety in the Outpatient World
The focus of safety until recently on
the hospital
 Controlled hospital environment vs. less controlled
practice environment
 Availability of patient records
 High risk vs. lower risk environment
 Long encounters vs. short encounters
 Focus of regulators/accreditation
Top Patient Concerns-National
When going into the hospital or receiving
health system care
Getting the wrong medications
Negative interaction of medications
cost of treatment
Procedural complications
Having enough drug information
Getting an infection during stay
Suffering from pain
61%
58%
58%
56%
53%
50%
49%
Top Patient Concerns in Emergency
Departments - National
Concerns elicited from telephone
Interviews with 767 patients receiving
care in ED
• Misdiagnosis-22%
• Physician Errors-16%
• Medication Errors-16%
• Nursing Errors-12%
• Wrong test/procedure-10%
Burroughs, TE, et al, Acad Emerg Med, 2005
What our patients (KP) are telling us
Patient safety to our patients means
 Proper diagnosis and treatment
 Sound communication – listening to the
patient
 Competent and Caring Staff
 Complete and accurate medical records
 Access to providers including specialists
 Lab tests when
What our patients (KP) are telling us
Medical mistakes were defined by patients
as
 Chart mix-ups
 Contamination
 Misdiagnoses
 Misidentification
 Exposure to infections,
 Wrong or inappropriate medications.
What our patients are telling us
(continued)
Why our patients think medical mistakes occur
 Inadequate staffing
 Inexperienced staff
 Inadequate time spent with patients
 Incomplete knowledge of a patient’s medical history
 Medication errors and possible interactions of
medications
 Not checking patient medications for possible
interactions
 Not taking the time to get to know patient or understand
their problems
What our patients are telling us
(continued)
How patients perceive their role
 Need to be proactive to prevent further
medical mistakes
 Need to communicate fully and honestly
with their caregivers, and providers need
to listen
 Ask questions and speak up (although
some said that they would not be
comfortable doing this)
Medical Office Safety
Medical errors and preventable events
--23.6% of 351 outpatient
encounters
Elder et al, “dentification of Medical Errors by Family Physicians during Outpatient Visits” Annals of Family Medicine 2: 125129
Medication errors
Errors were present in 68% of all
medication-related malpractice claims
The majority (62%) of these were outpatientrelated
Medication errors broken out (outpatient):



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
Ordering:
Transcribing:
Dispensing:
Administration:
Monitoring:
45%
4%
34%
21%
38%
* Data from the Malpractice Insurer’s Medical Error Prevention Study (MIMEPS)
Medications most commonly
involved
Data from the Malpractice Insurer’s Medical Error Prevention Study (MIMEPS)
Inpatient
 Electrolytes 14%
 Narcotics
13%
 Antibiotics 10%
 Anticoagulants 8%
Outpatient
 Antibiotics
19%
 Antidepressant 11%
 Narcotics
7%
 Oral steroids
5%
Adverse drug events in Medical
Office
• 25% of 661 patients
• 63% were associated with physician failure to
respond to medication-related symptoms
• 37% were associated with patient failure to inform
the clinician
• Medication classes most frequently involved



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SSRI – 10%
Beta Blockers – 9%
ACE inhibitors – 8%
NSAIDS – 8%
Gandhi et al, Adverse drug Events in Ambulatory Care, NEJM 348:1556-1564, April 17, 2003
Outpatient Medication Safety Assessment-KP
Incomplete orders
Inadequate/incomplete drug-allergy alerting
Inappropriate use and/or response to verbal orders
Incomplete/inadequate i.e. non-compliant) patient
identification practices
LA/SA and labeling issues
Inappropriate (i.e. unsafe) storage of medications
Lack of independent double-checks, where
needed/appropriate
Why is this so hard?
Complexity
Management System
Staff
Equipment/
Technology
Environment
Patient
Powerful drugs
Highly technical equipment/products
Rapid decisions; time pressured
Many care givers; multiple “handoffs”
Task-based versus Systems-based
Limited resources
Complex human factors
High acuity illness / injuries
Ambient environment prone to
distraction
Variable patient volume; variable
patient flow
Accident Causation Model - Swiss Cheese
NURSE
MD
Modified from Reason, 1991 © 1991, James Reason
Result of Our Current Error
Model: Cycle of Error
Quiet
period
Bad
Outcome
Shift in loci
of failures
More complex,
brittle system
Remedial
action
Overt
Retrospective
Mechanical
Review
Failure
15%
Classification
Human
Error
85%
Complex
System
Failure
0%
Copyright © 1997 by Richard I. Cook, M.D.
Why is this so hard
• Trained to be perfect
• Well trained individuals will deliver errorfree performance if they are paying
attention and trying hard
• Shame, blame, train
• Culture is so pervasive, what’s the use of
trying?
Why is this so hard?
• We have always done it that way
• Never happens here phenomenon
• We can’t afford it-takes too much time
• It’s not convenient
• What you have to say is not important
• What I have to say is not important
• Technology will fix the problem
Why is this so hard?—the human
condition
Limited memory capacity
Limited mental processing capacity
Limits imposed by stressors
Limits imposed by fatigue and other
physiological factors
Compounded by:
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
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poor group dynamics
Unrealistic attitudes
Staffing challenges
Environmental factors
Drifting/Migration
Clinical work is founded on tried and tested
ways of diagnosing and treating patients
Flexibility is necessary adaptation to
changing circumstances
Drifting is casual and inappropriate
departure from good clinical practice
Generally starts out with plausible reasons
for breaking a rule
Moves into ignoring rules
Migrates into becoming socially accepted
and perhaps organizationally sanctioned
Drifting—what makes an
organization vulnerable
Blaming front line workers
Denying the existence of systemic
error
Pursuit of productivity and financial
indicators
Leads to quick fixes solving the
immediate problem but ignoring the
underlying problems
Reason
Tucker and Edmonson
Drifting—masking the problem
Insidious—happen over time
Absence of incidents
Tolerance by management because
nothing “bad” happens
Tendency to become more lax over
time
Vaughn
The world of work
“LEGITIMATE”
SAFE SPACE
“ILLEGITIMATE”
SAFE SPACE
“ILLEGITIMATE”
NOT SAFE
“work-a-rounds”
Policy/
Procedures
VERY SAFE
G. Eric Knox, MD
Professor, OB-GYN
University of Minnesota
Potential
Event
SAFE
UNSAFE
Renee Almaberti – Systems Migration to Boundaries
ARE WE DRIFTING?
What you can do
Ensure staff are provided training and education that
allows them to perform their job safely.
Encourage the active engagement of staff in safety related
activities.
Recognize and reward staff for working safely.
Create and maintain a climate of “psychological safety”
where it is easy for staff to speak up, including reporting
what is getting in their way of performing safely.
Address identified safety issues in a timely manner.
Provide relevant data and information to staff that further
increases their situational awareness and understanding
of safety-related risks and hazards.
What you can do
Communicate your expectations to staff concerning their duty
to avoid unsafe (i.e., “at-risk”) behaviors and report errors
and unsafe conditions.
Conduct routine observations, and through conversation and
coaching, help staff make safer choices and reduce their
own tolerance for risk-taking.
Remove incentives for unsafe behaviors and respond to
them, regardless of outcome, in a “just manner”.
Ensure line managers are accountable for the safety
performance of their employees.
“Safety-Focused” Activities
Safety Walkarounds
Huddles, Briefings, and Debriefings
Use of SBAR
Observation and Coaching
Incident Investigation…to Learn
Application of “Just Culture”
principles