Transcript Reducing Medical Errors, Promoting Patient Safety Sharon Levine

Reducing Medical Errors,
Promoting Patient Safety
Every Patient’s Right
Everyone’s Responsibility
Primum non nocere - Hippocrates
Sharon Levine, MD
Associate Executive Director
Kaiser Permanente
October 20-21, 2008
Beijing, China
“Medicine used to be simple, effective and
relatively safe - now it is complex, effective,
and potentially dangerous”
Sir Cyril Chantle
“44,000-98,000
patients die each year in
hospitals from medical error”
May be as
IOM report
high as 195,000 deaths per year
Health Grades 2004
Our Challenge:
Preventing harm to patients from the care
intended to help them
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Accidental Deaths in the U.S.
(National Safety Council, Harvard School of Public Health, 1999)
120,000
120,000
100,000
80,000
60,000
43,649
40,000
14,986
20,000
3,959
329
0
Medical Error
Deaths
MVA Deaths
Fall Deaths
Drowning
Deaths
Plane Deaths
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How Do We Compare?
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
1,000,000
10,000,000
Number of encounters for each fatality
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Top Patient Concerns About
Hospital Stays
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Negative interaction of medications
Getting the wrong medications
Cost of treatment
Procedural complications
Having enough drug information
Getting an infection during stay
Suffering from pain
58%
61%
58%
56%
53%
50%
49%
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Basis Of Error– Complexity
Management System
Staff
Equipment/
Technology
Environment
Patient
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Powerful drugs
Highly technical
equipment/products
Rapid decisions; time
pressured
Many care givers; multiple
“handoffs”
Task-based versus Systemsbased
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Limited resources
Complex human factors
High acuity illness / injuries
Environment prone to
distraction
Variable patient volume;
variable patient flow
Requires more than “paying attention” and “trying hard”
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Basis of Error - Complexity
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80% medical error
is system derived
95% mistakes—
the good guys
Identify and
address the human
factors
Fix the system
Understand the
difference
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“Culture of Safety”
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Awareness, understanding, and ownership of safety
by all
Constant vigilance to prevent error
Learning from errors that do occur, and minimize
chance of recurrence
Teamwork, not hierarchy or autonomy
Communication and hand-offs
Non-punitive environment - encourage reporting of
errors and near-misses
Systems to mitigate “human factors”
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Memory capacity
Mental processing
Stressors: fatigue, emergencies
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Behavior
Biggest barrier to preventing errors – punishing
people for making mistakes
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Human error--inadvertently doing other
than what should have been done; slip,
lapse, mistake - console
At risk behavior - behavior where risk is
not recognized, or is mistakenly believed
to be justified - coach
Reckless behavior - conscious disregard
of a substantial and unjustifiable risk –
remedial, then disciplinary action
David Marx
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“Culture of Systems”
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From patient-specific to systems view
Indentifying patterns of error
Standardization where appropriate:
processes, procedures, checklists,
standardized orders
Care team accountability for error
identification and elimination
Expert team vs. team of experts:
communication, simulation, attention to
hand-offs
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Drivers of Hospital Mortality and Morbidity
Goals
Drivers
Focus Areas & Initiatives
Infection Reduction
No Needless
Harm/Deaths
Falls and pressure ulcers
High Alert Medication Program
Highly Reliable Surgical Teams
Reduce
Hospital
Mortality and
Morbidity
EvidenceBased Care
Appropriate
Care Setting
Disease-specific care: AMI, HF,
PN, SCIP, CVA, glucose control
Early goal-directed therapy
Anticipating end of life: Palliative
Care, Advance Directives
Access to alternative care
settings: SNF, HH, rehab
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High Alert Medication Program
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High Alert Drug List
Standardize: policies and procedures
Education, training and retraining
No-interruption zone, -wear
Peer observations
Measure, monitor, feedback
Peer group: share learnings
Leadership focus, oversight
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MedRite
Zone
The Zone is an area marked out
in front of the PYXIS to signify a
“no interruption” area.
Use of tape is a common zone
indicator in hospitals such as in
the OR and Pharmacy
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No Interruption Wear (NIW) is
the tool that helps minimize
interruptions during medication
administration
Worn ONLY during the
Medication administration
process
Allows the nurse to be
“interrupted” at appropriate
times
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Percentage change
from 1st mean (13.23
Jan to June ’06) to 2nd
mean (26.0) June to
April ’07: 97%
From April ’07:
Days since last event:
445 and counting
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System Redesign for Safety:
Highly Reliable Surgical Teams
From “Art to Science” –
Translating Evidence into Benefit
Clinical
Research
Evidence
Implementation
Benefit
REDESIGNING
PROCESSES
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System Redesign for Safety
Clinical
Research
Evidence
Implementation
Check lists
Safety Summit
Teamwork
Safety team in every OR
Time-out
Standardized orders
Standardized
orders
Checklist for every role
Benefit
Observation/audit
Debrief
Simulation
Training
Report cards
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Early Evidence of Benefit
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40% reduction in surgical complications
since 2001
From one surgery-related injury per 48 days
(2003 to 2007) to one in 280 days (and
counting) 2008
Significant and sustained improvement: in
abx use/time/duration (97%); normothermia
(95%); beta blocker use (97%)
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Early Evidence: Surgical Care
Improvement Program (SCIP)
100%
Regional SCIP
Performance
Quarter 1 2008
90%
80%
70%
SCIP Composite
60%
50%
of Antibiotic
Choice, Timing
and Duration
SCIP Abx Timing:
96%
SCIP Abx Choice:
98%
SCIP Abx Duration: 95%
Hair Removal:
99%
Normothermia:
92%
Beta Blocker:
97%
VTE composite:
94%
40%
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