Transcript Patient Safety

Medication errors
and patient safety
Vic Vernenkar, D.O.
Department of Surgery
St. Barnabas Hospital
Quality in Healthcare
Begins with ensuring patient safety
Patient safety
Freedom from injury or illness resulting from
the processes of healthcare
Healthcare errors
Top worry of patient!
Healthcare errors
 Failure
to diagnose / incorrect diagnosis
 Failure to utilise or act on diagnostic
tests
 Inappropriate use or outmoded
diagnostic tests / treatments
 Failure to monitor or provide follow-up
 Wrong site surgery, medication errors
 Transfusion mistakes
Healthcare errors
 Nosocomial
infections
 Patients falls
 Pressure sores
 Phlebitis associated with intravenous
lines
 Restraint related strangulation
 Preventable suicides
 Failure to provide prophylaxis
How big is the problem?

USA
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errors by HCWs affect about 3-4% patients
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mean of 7% ADEs
>7,000 ADE deaths / year
2 million nosocomial infections / year
average ICU patient experiences almost 2 errors per day
each year, 44,000 - 98,000 deaths due to medical
errors
annual cost of medical errors: US$29 billion
Medication errors
 Prescribing
errors
 Administration

errors
includes failure to monitor drug levels and
side effects of treatment
Medication errors

Rate of 3.99 per 1000 medication orders (Albany, NY,
USA)

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a third had potential to cause adverse events
Common factors
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failure to take account of declining renal/hepatic function
failure to check for possible allergic responses
using wrong drug name or means of administration
miscalculation of dosage
prescribing an unusual critical frequency of dose
Lesar et al. Factors related to medication errors. JAMA 1997; 277: 312-7
Why did it happen?
 Technology
e.g. infusion pumps
 Many care-givers
 High acuity of illness / injury
 Environment prone to distraction
 Time-pressured, need to make quick
decisions
 High volume, unpredictable patient load
Key reasons
 Patients
are more at risk than non-patients
 Medical interventions are, by their nature,
high-risk procedures - small error margins
 Medicine remains an inexact, hands-on
endeavour
Errors are inevitable
………….but most are preventable
Facts
 Often
it is the best people who make the
worst errors
 About 90% of errors are not culpable
 But some people knowingly adopt
behaviors more likely to produce error substance abuse, long working hours
Organisational accident model
Organisational
and
corporate culture
Management
decisions and
organisational
processes
James T Reason
Contributory
factors
influencing
clinical practice
Task
Defence barriers
Accident
or
incident
Error
producing
conditions
Errors
Violation
producing
conditions
Violations
Process review and change
Whose job is it?
- Risk Manager?
Lessons from past

Problems often formally recognised when there
is a major incident
 Methodologies for organisational analysis not
well developed
 Short-term corrective action not well sustained
 Problems in dealing with aftermath of service
failure - grievance of victims and their families
Cycle of prevention
Failure in standard of care
Prevent similar problem
Detect
Deal with consequences
Sustain corrective action
Take corrective action
Analyse
Recommendations
 Leadership
priority
 Clear
organisational commitment to
patient safety (infrastructure and
resources)
 No-blame
culture
Culture of safety
 Integrated
pattern of behaviour
 Underlying
 Continuos
philosophy and values
search to minimise hazards and
patient harm
Culture of safety
 Acknowledges
high risk, error prone
nature
 Widespread shared acceptance of
responsibility for risk reduction
 Open communication about safety
concerns, non-punitive environment
 Reporting of errors and safety concerns
Culture of safety
 Learns
from errors
 Accountability
for patient safety
 Organisational
structure, processes,
goals and rewards aligned with
improving patient safety
Strategy 1: teams
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Implement known safe
practices
Design work so that it is
easy to do it right and
hard to do it wrong
Reduce reliance on
memory
Less steps
Constraints
Protocols and checklists
Clinical Pathways
Care process models
Teams - lessons from the navy

Members monitor each other’s performance and
stepped in to to help out. TRUST was an implicit
part of this.

Giving and receiving feedback was norm for all
team members. Understanding each other’s
role is important part.

Communication was made real: senders
checked their messages were received as
intended.
Teamwork and team leadership
 Good

organisational culture of welcoming openness
and monitoring changes that result
 Good

teams do not develop on their own
team leadership is essential
development is vital across organisation
Hospital team activities

Improving information access

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Standardising and simplifying medication procedures

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teams worked on high risk and high error-potential drugs
Restricting physical access to potentially lethal drugs

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hospital teams redesigned medication administration records
chemotherapy drugs, concentrated KCl, NaCl
Educating clinical staff about medications

to assess knowledge deficiencies, drug knowledge, awareness
for potential for error
Silver et al. Reducing medication errors in hospitals: a peer review organisation
collaboration. J Qual Improvement 2000; 26: 332-40
Strategy 2: education

Recognise effect of
fatigue on
performance
 Education and
training for safety
 Teamwork
 Reduce known
sources of confusion
Awareness
Education
Training and supervision

Training in organisational aspects of care

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medical training focuses on diagnosis and
management of individuals
Training in skills of risk management
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understanding of inevitability of human error
factors associated with errors, mistakes and near
misses
appropriate checking behaviour, safe handover
team work
Strategy 3: accountability
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Acknowledge error
Apologise
Provide remedial care
Conduct root cause
analysis
Fix system or process
problems
Risk management
system
Sentinel event team
Clinical incident reporting
system
 Success
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depends on change in culture
staff must be convinced of importance of
patient safety
board has to agree on “no-blame” culture
systematic and strategic approach to risk
management
reporting system must produce reports that
are timely and informative
Main Incident Page – Reporting Person
Risk Management
System (RMS)
Fall Report
Fall Report
Sharp Report
Reporting Nurse
Fall Report
Sharp Report
Nurse Manager
Sharp Report
Sharp
Report
Follow-up Doctor
Supervisor
/ Manager
Sharp
Report
CMB /
Administrator
Sharp Report
Sharp Report
Sharp Report
Doctor
Management
Fall Report
Reporting Doctor
Reporting Person
CEO/CMB
Assist. Director
Nursing
Sharp Report
Injured Staff
Fall Report
Medication
Medication
Error Report
Error Report
Pharmacy
Manager
Head of
Department
/ Division
Chairman
Dept Of Quality
Management
Medication
Error
Report
Infection
Control
(Sharp only)
Medication
errors
Sharps injury
Clinical incident:
morbidity
mrotality
surgical incident
Patient falls
RMS
Risk Management System
Cat I
CMB and DQM informed
within 6 H
SET
Root cause analysis by
appointed team
Cat I or Cat II?
Cat II
Report with investigation findings
and recommendations to Division
Chairman
Report to CMB, CEO, and DQM
Recommendations
reported to SET
HOD/Managers monitor to
assure compliance with
corrective actions and
report back to RM
Yes
Recommendations
implemented?
No
Operations informed to
implement
recommendations
DQM presents findings,
recommendations, summary analysis,
and follow-up to RM, QC, reports
number of events quarterly per
department to QC as part of BSC
Complaints
Sentinel Event Team
 CEO
 CMB
 Administrator,
 Director,
Nursing
QM
 Administrator, Medical Board
Sentinel Event Team
Incident reporting, complaints
Category I
SET discussion
Appoints team to investigate
Root cause analysis
 Reviewing
the process
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What happen?
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How did it happen?
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Why did it happen?
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What can we do differently?
MOH requirement
 Report
within 7 days of knowing
 Submit full report within 60 days
 De-identify
 Objective: how can we improve

what happen, how did it happen, why did it
happen, can we do differently?
Impact
“As evidence in support of the value of the changes made
to our processes, we observed no further fatal ADEs…..”
John Rex et al. Systematic root cause analysis of adverse drug events
in a tertiary referral hospital. J Qual Improvement 2000; 26: 563-75
Key findings in IOM report:
• Errors occur because of system failures
• Preventing errors means
designing safer systems of care
Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine, 2000.
IOM report
 Avoid
reliance on memory
 Use constraints or forcing functions
 Avoid reliance on vigilance
 Simplify key processes
 Standardise work processes
Institutional practice
Clinical risk management system
Plan
 Process
 People

Culture
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LEADERS