Transcript Health & Safety Survey Project: Patients

Is your dialysis unit safe?
Are there opportunities to improve
safety?
We are all human
We make mistakes
Mistakes are common.
They occur daily.
Mistakes are part of our every day lives.
When you are admitted to a hospital (or
dialysis unit) you expect
NO MISTAKES
Institute of Medicine Report
(1999)
44,000 – 98,000 people
die each year from
medical errors that
occur in hospitals.
That's more than die
from motor vehicle
accidents, breast
cancer and AIDS-combined--making
medical errors the fifth
leading cause of death
in this country.
February 18, 2003
DURHAM, North Carolina (AP) -- A
teenager from Mexico who mistakenly
received organs from a donor with a
different blood type was not expected to live
more than a few days, a family friend said
Tuesday.

This was actually the second girl in several
months to die after receiving a transplant
with the wrong blood type

Dallas, 2002: A patient received a partial
liver transplant from her father (type A) but it was her mother who had compatible
(type O) blood.

Laboratory mix-up was not detected until
19 days post-op
“There’s more double-checking and
systematic avoidance of mistakes at
Starbucks than at most health-care
institutions.”
- Carolyn M. Clancy, Director AHRQ
“It is fundamental that the
hospital shall do nothing to harm
the patient … my view you know
is that the ultimate destination of
all nursing is the nursing of the
sick in their own homes … I look
to the abolition of all hospitals
and workhouse infirmaries. But
it is no use to talk about the
year 2002.”
Florence Nightingale
Letter to Henry Bonham Carter circa
1867
U.S. Has Most Medical Errors
Schoen et. al., Health Affairs Nov 3, 2005

34% of US patients said they were given a wrong
medication or dose, experienced a medical mistake in
treatment, received incorrect test results, or had a delay
in being notified of abnormal test results in the past 2
years.

1/3 US patients had a physician visit in which their test
results or medical records were unavailable, or a
physician ordered a test that had already been done.
Safety Conundrum
• Medical workers are expected to function
without error.
• Errors are made by highly competent,
careful and conscientious people for the
simple reason that everyone makes
mistakes every day.
Lucian Leape, 1997
The “Blame Trap”
Blame is universal, natural, emotionally
satisfying, and legally convenient, it does
nothing to make healthcare safer.
-- Reason, 1994
Systems can be designed...
• To help prevent errors
• To make them detectable so that
they can be intercepted
• To mitigate them if they are not
intercepted
Dialysis Chains:
Top Patient Safety Issues
•
•
•
•
•
Patient Falls
Medication Errors
Access-Related Events
Dialyzer Errors
Excess blood loss and prolonged
bleeding
December 18, 2002
Risk of Hip Fracture Among Dialysis
and Renal Transplant Patients
• Incidence of hip fracture in dialysis
patients: 2.9/1,000 patients/year
• Extrapolation to national incidence:
800 hip fractures each year in
dialysis patients.
Medication Errors: Major Safety
Issue in Hospitals
Pharmacists on Rounding Teams Reduce
Preventable Adverse Drug Events in Hospital
General Medicine Units
Kucukarslan SN, Peters M, Mlynarek M, Nafziger DA
Arch Intern Med. 2003 (Sept); 163:2014-2018
Health & Safety Survey Project:
Patients & Professionals
Sponsors
Partners
Funding by Abbott Laboratories & CMS Special Project
Patient Survey
• Invitations to participate in an anonymous
survey sent to 3,587 patients drawn from a
representative national patient sample
• Network #1 implemented the patient
selection and coordinated survey mailing
and responses
• Surveys completed by 1,762 patients
Patient Survey
Sample Characteristics
Mean Age 64 yrs.
Gender: 54% males
Race: 67% Caucasian, 28% African Amer.
Dialysis Type: all in-center hemodialysis
Vascular access: 21% catheter
Professional Survey
• Invitations to participate in an anonymous
web-based survey widely distributed by
RPA, Networks, Professional Meetings
• Web-based Surveys completed by 649
professionals
Percent Professional Respondents by Role Group
50%
Percent Respondents
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Assistants
Nurses
Managers
Role Groups
Docs
Percent ESRD Patients & Survey
Respondents by Network
Figure 1: Percent ESRD Patients and Survey Respondents by Network
12%
All ESRD Patients
10%
10%
Survey Sample
9%
9%
8%
7%
7%
Percent
7%
6%
6%
6%
6%
6%
5%
4%
4%
4%
4%
8%
8%
7%
7%
6%
6%
6%
5%
4%
4%
4%
4%
4%
3%
4%
3%
5%
5%
5%
5%
4%
3%
2%
0%
1
2
3
4
5
6
7
8
9
10
Network
11
12
13
14
15
16
17
18
Patient Falls: Patients’ View
Patient Survey last 3 months:
• 95% patients had never fallen at the
dialysis unit
– 5% fell: extrapolated nationwide – 15,240 falls
• 55 patients (3.1%) reported falls in the unit
– Some had several falls – mean # falls 1.3
– Reason for falls:
• Feeling dizzy or weak: 60%
Needle Insertion
Patient Survey: Past 3 months:
• 46% patients report staff sometimes,
usually or always has problems inserting
needles
– 6% say the last time there were problems,
staff tried to insert the needle more than 3
times before getting help
– Additional 24% say staff tried 3 times before
getting help
Medication Safety: Patients’ View
Patient Survey: Past 3 months:
• Physician review of medications with
patients
– 40% patients report that they discuss their
meds with their doctor only “sometimes.”
Medication Safety: Staff View
Professional Survey: Past 3 months
• 43% professionals report 1 or more instances of
patient given the wrong medicine or medicine at
wrong time
• 63% report patients fail to receive 1 of their
meds at times
• 37% report that a patient is given wrong dose of
a medication at least once
• Overall 77% staff indicate a patient had a
medication omission or error in past 3 months
Handwashing: Patients’ View
Patient Survey: Past 3 months:
• 11% of patients report seeing nurses or
technicians who do not washing their
hands or change gloves before touching
their access site
Handwashing: Staff View
Professional Survey: Past 3 months:
• 27% professionals reported observing staff
fail to wash hands or change gloves
before touching a patient’s access
Set-up Predialysis: Patients’ View
Wrong Dialyzer Set-ups
• 17% patients reported problems with settings on
their dialysis machine
• 3% wrong dialyzer set up for treatment
• 2% wrong dialyzing solution set up
3% patients report a treatment when weight not
recorded
6% patients report a treatment when BP not
obtained prior to treatment
86% Staff report a patient blood sample was not
taken when ordered in past 3 months
Overall Assessment of Safety
Patients:
• 27% patients have seen at least 1 medical
mistake in past 3 months
• 16% patients say they sometimes feel
unsafe at the dialysis center
• 49% patients sometimes, usually or
always worry that someone will make a
mistake
Overall Assessment of Safety
Professionals
• 30% professionals said mistakes occur more
than rarely
• 30% professionals said the last observed
mistake was not trivial
• Medical mistakes are connected to failure to
adhere to procedures (59% of staff reporting
medical mistakes)
• Most believe their dialysis facility has a positive
patient safety environment
50%
40%
30%
20%
10%
Percent Professional Respondents
Percent Professionals Indicating Each Reason for Medical Mistakes
60%
0%
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Reasons for Medical Mistakes
Conclusions
• Patients worry about medical mistakes
more than they experience them (49%)
• Most staff (87%) are aware that medical
mistakes have occurred in past 3 months
Conclusions
• Medication errors recognized frequently by
patients and staff
• Patient Falls remain frequent source of adverse
events
• Handwashing is recognized as patient safety
issue in dialysis units
• Correct dialysis set-up and predialysis
procedures are safety issues
• Adherence to procedures is a major source of
medical mistakes
What Can You Do?
• Wash your hands
• Review medications with your patients
frequently
• Assess patients for risk factors for falls
• CMS new Conditions of Coverage require
a Quality Assessment Performance
Improvement Program – participate
• Help design a “culture of safety” in your
unit