Transcript Sept23 Ch 7 Human Error in Healthcare Graduate Student

Ch. 7 – Human Error in
Health Care
ETM 591
Adams, Duong, Lockwood, Meador
September 23, 2010
Presentation Summary
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Introduction to Human Error in Health Care
Facts / Figures
Human Error in Medication
Human Error in Anesthesia
Human Error in Medical Devices
Human Error in Misc. Health Care Areas
Useful Guidelines to Prevent Occurrence of Human Error
Scholarly Works on Human Error in Health Care
Conclusion
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Introduction to Human Error in Health Care
• History of human error in health care traced back to anesthetic death in 1848 1,2
• Studies regarding human error started to be conducted in 1950s and 1960s
(main focus on anesthesia-related deaths)3,4
• 8th leading cause of death in U.S.
• Annual total national cost of medical adverse events is estimated to be $38
billion ($17 billion thought to be preventable)5
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Health Care Related Error – Facts/Figures
• Each year, more than 100,000 U.S. citizens die due to human error in the
health care system5
• More than 50% of technical equipment problems linked to operator error 9
• 7,391 people died due to medication errors (1993)7,10
• $7 billion – annual cost due to medication errors11
• Patient mistakenly give 120 cm^3 per minute of a powerful drug instead of 12
cm^3 per hour; patient died in New York City hospital (1990)19
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Human Error in Medication
• Medication Error – any preventable event that may lead to incorrect medication use or
patient harm while the medication is in the control of a health care professional,
consumer, or patient
• Types of Medications Errors:
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Omission error
Incorrect dose error
Incorrect time error
Incorrect drug preparation error
Prescribing error
Unauthorized drug error
Incorrect dosage form error
Incorrect administration method error
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Human Error in Medication
• Several Common Reasons:
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Poorly trained personnel
Illegible handwriting
Excessive Workload
Errors in labeling
Incorrect transcription
• Guidelines to Reduce Occurrence of Errors
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Write legibly or use computer generated prescriptions
Don’t leave medication near patient’s bedside
Check patient’s I.D. bracelet before administering medication
Carry out dosage calculations on paper, not in head
Carefully check drug label three times
Avoid distractions when preparing medication for administration
Others
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Human Error in Medication
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Human Error in Anesthesia
• Anesthesiology
– Element of Medicine to render patient insensitive to pain
• Defined in Two Ways
– Mistake: linked an actual or probable adverse out come
– Slip: did not occur according to the plan
• Risk of Death
– According to Canadian Medical Assoc. Journal, (Anaesthesia in
1984, How safe is it?)
• 1952-1984; decreased from 1 in 2,680 to approx 1 in 10,000
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Human Error in Anesthesia
• Common Anesthesia Errors
Incorrect
blood
transfused
Loss of
oxygen
supply
Breathing
circuit leak
Breathing
circuit
disconnect
Premature
extubation
Common
Anesthesia
Errors
Ampoule
swap
Wrong
selection
airway Mgt
method
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Drug
overdose
Hypoventilation
(operator
error)
Inadvertent
change in
gas flow
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Syringe
Swap
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Human Error in Anesthesia
• Methods to Prevent or Reduce Anesthetic Mishaps
Method I
Method II
Find out What Is going on
Collate all the Relevant information
Classify the problem errors and their
contributing factors
Design and Organize workspace
Assure equipment performance to effective levels
Supervise and Train
Develop preventative strategies
Use appropriate monitoring instrumentation and
vigilance aids
Implement strategies
Develop and closely follow all appropriate
preparation and inspection protocols
Review strategies
Act on incident reports in an effective manner
Recognize the limitation that influence individual
performance
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Human Error in Medical Devices
• Human factors related problems encountered by novice and highly
competent personnel
– Cognitive, perceptual, and physical abilities by user
• Medical devices with High Incident of Human Errors
Most Error
Prone
Least Error
Prone
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• Glucose Meter, balloon catheter
• Orthodontic bracket aligner
• Admin Kit for Peritoneal dialysis
• Cather Guide Wire
• Low Energy Defibrillator
• Continuous Ventilators,
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Human Error in Medical Devices
• Human Errors causing user-interface design problems
– Poorly designed labels, ambiguous displays, complex installation/maintenance tasks,
confusing operating instructions
• Medical Device-Associated Operator Errors
Inadvertent or untimely activation of controls
Incorrect interpretation of critical device
outputs
Mistake in setting equipment or device
parameters
Over reliance on medical device automatic
features
Failure to follow prescribed instructions and
procedures
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Human Error in Medical Devices
• Human Errors Analysis Methods for Medical Devices
Methods and Techniques
Failure modes and effect analysis (FMEA)
Fault Tree Analysis (FTA)
Markov Method
Force Field Analysis
Barrier Analysis
• Barrier Analysis
– Item posses various types of energy/can cause property damage and injury
– Identifies energy types and appropriate barriers
Advantages – Easy to Use/Apply
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Disadvantages – Promotes linear thinking
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Human Error in Miscellaneous Health Care Areas
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Emergency medicine
Intensive care units
Operating rooms
Radiotherapy
Image interpretation
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Human Error in Emergency Medicine
• 100 million emergency visits in U.S./year36
• Error result in substantial # of adverse events36
– Facts
• 90% are preventable37, 38
• Missed diagnoses ~4.3% of 1,817 acute cardiac ischemia patients
incorrectly discharged39
• 8 – 11% disagreement in interpretation of radiographs between
emergency radiologists & physicians40
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Reduce error by asking these questions39:
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Ways to make errors more visible?
Presence of pharmacologist?
Usefulness of computerized clinical information?
Adjusting change-of-shift & lengths of shifts?
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Human Error in Intensive Care Units (ICU)
• In 1960, 10% hospitals with › 200 beds in U.S. had ICU41, 42
• Currently more than 40,000 patients/day in ICU in U.S.
• Facts
– From 1989-1999, most critical incidents due to staff personnel
errors43
– 66% of incidents in 7 ICU in 1 year were human errors44
– 554 human errors in a 6-bed ICU in 6-month45
• 45% by physicians45
• 55% by nursing staff45
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Important Identified Factors43
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Poor communication
Inadequate training & experience
Staff shortage
Night time
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10 Useful Guidelines to Prevent Occurrence of
Human Error46
1. Simplify. Reducing # of process steps, nonessential
procedures, equipment, & software; # of times an
instruction is given, etc.
2. Redesign patient record for effectiveness. Currently
too voluminous with buried important information
3. Stratify. Avoid over-standardization
4. Make improvements in communication patterns. Team
members repeat orders to ensure instructions are clearly
& correctly understood
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10 Useful Guidelines to Prevent Occurrence of
Human Error46
5. Automate cautiously. Not over-automating because may
prevent operators from judging true system state
6. Respect human shortcomings. Memory limitations,
workload, stress, circadian rhythm, & time pressure in
designing work systems & tasks
7. Standardize. Limit unneeded variety: supplies, drugs,
equipment & rules. Procedure performed on regular basis
reduce error
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10 Useful Guidelines to Prevent Occurrence of
Human Error46
8. Use defaults effectively. Make correct action the easiest
one. Default as standard order or rule that work well if
nothing else intervenes
9. Use affordances. Designing features in items that
automatically force proper use by providing clues to
correct operation
10. Use sensible checklists. Developing & using checklists
sensibly & effectively
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Scholarly Works on Human Error in Health Care
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Reason, J. (2000). Human error: models and management. British Medical Journal, Retrieved from
http://www.bmj.com/content/320/7237/768.full?ijkey=1181633917c8e870e42b6e210c8ca71ef69c325a&k
eytype2=tf_ipsecsha
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Cochrane,G. Toit, R. Mesurier, R. (2010). Management of refractive error. British Medical Journal,
Retrieved from http://www.bmj.com/content/340/bmj.c1711.full?sid=87684ed7-3c41-49c6-a877c493c7f2e435
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Cooper, J. Newbower, R. Long, C. McPeek, B. (2002). Preventable anesthesia mishaps: a study of human
factors. Quality and Safety in Healthcare, Retrieved from http://qshc.bmj.com/content/11/3/277.abstract
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Leape, L. Woods, D. Hatlie, M. Kizer, K. Schroeder, S. Lundberg, G. (1998). Promoting patient safety by
preventing medical error. The Journal of the American Medical Association, 280(16), Retrieved from
http://jama.ama-assn.org/cgi/content/full/280/16/1444
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References
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1. Beecher, H.K. The First Anesthesia Death and Some Remarks Suggested by It on the Fields of the Laboratory and the Clinic in
the Appraisial of New Anesthetic Agents. Anesthesiology 2 (1941): 443-449.
2. Cooper, J.B., Newbower, R.S., Kitz, R.J. An Analysis of Major Errors and Equipment Failures in Anesthesia Management:
Considerations for Prevention and Detection. Anesthesiology 60 (1984): 34-42.
3. Edwards, G., Morlon, H.J.V., Pask, E.A. Deaths Associated with Anesthesia: A report on 1,000 Cases. Anesthesia 11 (1956): 194220.
4. Clifton, B.S., Hotten, W.I.T. Deaths Associated with Anesthesia. British Journal of Anesthesia 35 (1963): 250-259.
5. Kohn, L.T., Corrigan, J.M., Donaldson, M.S., eds. To Err Is Human: Building a Safer Health System. Washington, D.C: Institute of
Medicine, National Academy of Medicine, National Academies Press, 1999.
7. Dhillon, B.S. Human Reliability and Error in Medical System. River Edge, NJ: World Scientific Publishing, 2003.
9. Dhillon, B.S. Medical Device Reliability and Associated Areas. Boca Raton, FL: CRC Press, 2000.
10. Phillips, D.P., Christenfeld, N., Glynn, L.M., Increase in U.S. Medication-Error Deaths Between 1983 and 1993. Lancet 351 (1998):
643-644.
11. Wechsler, J. Manufacturers Challenged to Reduce Medication Errors. Pharmaceutical Technology February (2000): 14-22.
19. Belkin, L. Human and Mechanical Failures Plague Medical Care. New York Times, March 31, 1992, B1, B6.
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References
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36. Kyriacou, D,N., Coben, J.H. Errors in Emergency Medicine: Research Strategies. Academic Emergency Medicine 7 (2000):
1201-1203.
37. Wears, R.L., Leape, L.L. Human Error in Emergency Medicine. Annals of Emergency Medicine 34 (1999): 370-372.
38. Bogner, M.S., ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994.
39. Pope, J.H., Aufderheide, T.P., Ruthazer, R., et al. Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department.
New England Journal of Medicine 342 (2000): 1163-1170.
40. Espinosa, J.A., Nolan, T.W. Reducing Errors Made by Emergency Physicians in Interpreting Radiographs: Longitudinal Study.
British Medical Journal 320 (2000): 737-740.
41. Hospital Statistics: 1979 Edition. Chicago: American Hospital Association, 1979.
42. Knaus, W.A., Wagner, D.P., Draper, E.A., et al. The Range of Intensive Care Services Today. Journal of the American Medical
Association 246 (1981): 2711-2716.
43. Wright, D. Critical Incident Reporting in an Intensive Care Unit. Report, Western General Hospital, Edinburgh, Scotland, UK,
1999.
44. Beckmann, V., Baldwin, I., Hart, G.K., et al. The Australian Incident Monitoring Study in Intensive Care (AIMS-ICU): An Analysis
of the First Year of Reporting. Anaesthesia and Intensive Care 24 (1996): 320-329.
45. Donchin, Y., Gopher, D., Olin, M., et al. A Look Into the Nature and Causes of Human Error in Intensive Care Unit. Critical Care
Medicine 23 (1995): 294-300.
46. Crane, M. How Good Doctors Can Avoid Bad Errors. Medical Economics April (1997): 36-43.
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Conclusion
• Questions / Comments / Discussions
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