Transcript Medical Errors - Foma District 2

Leo Alonso, D.O.
16th Cardiovascular and Medicine Symposium
April-May 2015
MEDICAL ERRORS
GOALS
Quantify magnitude of problem
 Identify common medical errors
 To be able to realize what are the cognitive
patterns that lead to medical errors
 Suggestions and solutions to prevent some of
these errors

DEFINITION
•
•
A medical error occurs when a health-care
provider chooses an inappropriate method of
care or improperly executes an appropriate
method of care. Medical errors are often
described as human errors in healthcare.
However, medical error definitions are subject
to debate, as there are many types of medical
error from minor to major, and causality is often
poorly determined.
TO ERR IS HUMAN
•
IOM releases report To Err is Human (1999)
–
–
–
Estimates 44,000 to 98,000 unnecessary deaths
each year due to medical error
Estimated 1,000,000 excess injuries due to
medical error
Numbers based on the MPS and extrapolated to
the general population
ESTIMATED DEATHS DUE TO MEDICAL ERROR
Source – The Philadelphia Inquirer
DEATHS DUE TO MEDICAL ERROR
•
44,000 to 98,000 unnecessary deaths each
year
–
–
–
More Americans are killed in US hospitals every 6
months than died in the entire Vietnam War
Death rate equivalent to three “jumbo” jet crashed
every two days
More deaths than the number who die from
Alzheimer’s disease each year
IOM 2006 STUDY
Errors harm at least 1.6 million/yr.
 400,000 preventable drug related injuries
 In 2000 alone extra medical costs related to
preventable drug injuries….$887 million..and
these were only Medicare pts.
 Lost wages and productivity not factored in.

VIEWS OF PRACTICING PHYSICIANS AND
THE PUBLIC ON MEDICAL ERRORS
Response
Physicians
(N = 831)
All Respondents
Public
(N = 1207)
P Value
percent
Error made in own or family member’s care
35
42
<0.001
Health consequences: (Serious)
18
24
<0.001
Parties who had “a lot” of responsibility for the error:
(Doctors)
70
81
<0.001
Health professional told respondent an error had been made
31
30
<0.001
1
23
<0.001
Confidential
86
34
<0.001
Made public
14
62
<0.001
Respondents reporting an error
Possible solutions to the problem of medical errors
Increasing lawsuits for malpractice
Hospital reports of serious medical errors should be:
Source- Blendon, 2002
HOW TO MEASURE ERRORS?
Negligence cases……1% of hospital admissions
 Measurable adverse events occurring soon
after the event.
 Do we all agree on what the standard of care
is?
 Evidence-based medicine

MOST COMMON MISDIAGNOSIS
1] Infection
 2]Neoplasm
 3]MI
 4]Pulmonary Emboli
 5]Cardiovascular Disease

TYPES OF ERRORS

Diagnosis
 Error
or delay
 Failure to employ indicated tests
 Use of outmoded tests or therapy
 Failure to act on results of monitoring or testing
TYPES OF ERRORS

Treatment
 Error
in the performance of an operation,procedure
or test
 Error in administering the treatment
 Error in the dose or method of using the drug
 Avoidable delay in treatment to an abnormal test
 Inappropriate (not indicated) care
TYPES OF ERRORS

Preventative
 Failure
to provide prophylactic treatment
 Inadequate monitoring or follow-up treatment
 Other:
Failure of communication
Equipment failure
Other system failure
PUBLIC PERCEPTION OF MEDICAL ERRORS
RELIABILITY THEORY
“Failure rate” and “hazard rate” are used
interchangeably
 Used primarily for mechanical objects (cars,
trains , planes, etc.)
 May differ from perceived reliability

HOW HAZARDOUS IS HEALTH CARE?
Dangerous
(MODIFIED FROM LEAPE)
(>1/1000)
Total lives lost per year
Ultra-Safe
Regulated
(<1/100K)
HealthCare
100000
Driving
10000
Scheduled
Airlines
1000
100
Mountain
Climbing
Bungee
Jumping
10
European
Railroads
Nuclear
Power
Chemical
Manufacturing
Chartered
Flights
1
1
10
100
1000
10000
100000
1000000
Numbers of encounter for each fatality
10000000
EHR/EMR





When used effectively, EHRs can enable providers to deliver health care
more efficiently. For example, they can:
■Eliminate the use of medical transcription and allow a physician to enter
notes about a patient’s condition and care directly into a computerized
record;2
■Eliminate or substantially reduce the need to physically pull medical charts
from office files for patients’ visits;
■Prompt providers to prescribe generic medicines instead of more costly
brand-name drugs; and
■Reduce the duplication of diagnostic tests.
EHR/EMR




The adoption and proper use of EHRs could also improve the
quality of health care. Among other things, they could:
■Remind physicians about appropriate preventive care;
■Identify harmful drug interactions or possible allergic
reactions to prescribed medicines, and
■Help physicians manage patients with complex chronic
conditions.
EMR TODAY
Feds set aside $30 billion in stimulus money
just for EMR 3 yrs.ago.
 Mutiple studies question validity of basic
assumption

TENSIONS AND PARADOXES IN ELECTRONIC PATIENT
RECORD RESEARCH: A SYSTEMATIC LITERATURE
REVIEW USING THE META-NARRATIVE METHOD
•
•
•
•
Findings suggest that EMRs will always require
human work to re-contextualize knowledge for
different uses
Secondary work (audit, billing, research) may
become more efficient
Primary clinical work may be made less
efficient.
Smaller systems may be more
efficient/effective than larger systems
COST OF EMR
Steep price puts into question will value be
derived from adoption?
 Office of Nat’l Coordination for Health
Information found that any gains in efficeincy
were offset by reduced productivity.
 Added staff requirements to maintain/service
the system.
 Privacy risks

Why Do We Commit Errors?
WHY DO SO MANY MISTAKES OCCUR?
A] Because we are hard-wired a certain way
 B] Because of the complexity of decisions and
information processing
 C] Because of the work environment
 D] Because of time constraints
 E] Because system errors are not analyzed

HUMAN ERROR
•
•
Extensively studied in other industries
Cognitive psychologists divide errors into:
–
Errors occurring in “automatic mode”
•
Slips
–
–
Occur during fatigue, interruptions, anxiety
Errors occurring in “problem solving mode”
•
Mistakes
–
Occur due to incomplete knowledge and the tendency to apply
rules to simplify problem solving
COMMON COGNITIVE ERRORS

Context errors: The physician inappropriately
limits consideration to only one set of
diagnostic possibilities, in lieu of others. For
example, gastrointestinal causes are not
considered for a patient presenting with chest
pain.
CONTEXT ERRORS

Location of Patient ( “Location Errors”)
 Fast
track versus main ED
COMMON COGNITIVE ERRORS


Availability errors: The physician chooses the most likely
diagnosis over conditions that are more rare, or they choose
conditions they are most familiar with. An example would be
the patient with a dissecting aortic aneurysm whose chest pain
is attributed to a musculoskeletal strain.
Premature closure: Once a plausible condition is identified,
other possibilities are not fully considered; we just stop
thinking.
WHY SO FAST?

“Pattern Recognition”
 Reflects
an immediacy of perception
 Occurs largely without conscious analysis
 Draws heavily on doctor’s visual appraisal
of patient
 It is not a linear, step-by-step combing of
cues
WHY SO FAST?
Medicine, unlike other professions,
involves “thought-in action”.
 Doctors think of a diagnosis from the
second we meet a patient.
 Most doctors come up with 2 or 3
diagnosis from the outset of meeting a
patient.

WHY SO FAST?
Doctors develop their working
hypothesis from a very limited body of
information
 To achieve this heuristic thinking is
employed.
 Heuristic; Of or relating to a usually speculative

formulation serving as a guide in the investigation
or solution of a problem.
PRICE IMPLIES QUALITY
Beer
 Taste vs. Price

HEURISTICS IS THE FOUNDATION OF ALL
MATURE MEDICAL THINKING
You must me cognitive of which
heuristics your using
 How your inner feelings may influence
these reasoning processes
 The correct shortcut (heuristic) must
be employed at an optimal emotional
temperature

ATTRIBUTIONAL ERRORS
More common
 When patients fit a negative stereotype
 “Sense of Disgust”

 Intoxicated
 Violent
 Smokers
 Pt’s
perceived as not caring for themselves
NEGATIVE FEELINGS
Psychiatric patient
 Histrionic
 Obesity
 Race/ethnicity

 “Hispanic
Panic”
Fibromalgia
Toradol Allergy
Intoxicated
YERKES-DODSON LAW

There is an optimal level of arousal for a given
task
“THE SUCCESSFUL DECISION-MAKER”
Has an ergonomically optimized work space
 Well rested and well slept
 Not driven by throughput pressures
 Is aware of the various cognitive and affective
biases
 Is able to safely blend cognitive, intuitive and
analytical styles according to the specific task
at hand

SAFETY IS RELATIVE
COGNITION AND EMOTION ARE
INSEPARABLE
Not discussed enough in medical training is
how our emotions influence our perceptions
and judgments.
 Most errors are not technical, e.g. prescribing
the wrong drug or mislabeling an X-ray.
 Most errors are mistakes in thinking.

INTUITIVE VS. ANALYTICAL DECISION-MAKING







Cognitive style
Awareness
Conscious control
Automaticity
Rate
Reliability
Errors






Effort
Predictive power
Emotional valence
Detail on judgment process
Scientific rigour
Heuristic
Systematic
Low
High
Low
High
High
Low
Fast
Slow
Low
High
Normative
Few but large
distribution
Low
High
Low
High
High
Low
Low
High
Low
High
HOW TO THINK OF ERROR?
A
systems failure
This
is the starting point for
redesigning the system and
reducing error
PATIENT IDENTIFIER
Same last name with more than one pt. in
department with that name.
 Use patients name not the room number
 Ask the pt. what is their name when you enter
the room.
 Identify the pt. before drawing any lab or giving
any medication

PROPER LABELING

Label blood specimens immediately
RIGHT INTERACTION/ TEAM APPROACH




You order 2 grams of ceftriaxone for a meningitis pt. The RN
comes up to you and asks if you meant to write 1 gram instead.
Your reply should be:
A] “I’m the doctor and your the nurse, just follow my orders!”
B] Change the orders just to please the RN/
C] Thank the RN for pointing this out and explain your rationale.
WORK ENVIRONMENT
Studies show that clinical outcomes are better
in a team environment.
 Encourages questioning outcomes and
processes from patients and staff.

PROTOCOLS
Order sets
 Reduces odds of error with increasing
complexity
 Improves situational awareness

 STEMI
 Stroke
 Sepsis
 Trauma
COMMUNICATION
Inter-subjective understanding
 Aviation industry
 Verbal orders
 Rapid sequence intubation

 repeat
what was just ordered
CHECKLIST MANIFESTO
•
•
•
•
Atul Gawande , surgeon
Problem: Extreme complexity and
specialization.
Solution: Develop checklists and then
consistently use/improve them.
Checklists are used in avaition for years and
recently generated improved results in
medicicne

Real Cases
 60
yo F presents to ED c/o N/V that AM without any
abdominal or back pain. No CP or SOB. No c/o a HA
by RN or physician charting. Triage VS BP 215/130,
P86, T 97.1F, RR 18. Tx’ed with 10 mg IV Labetolol,
Zofran, Protonix 40 mg IV. 10 mEq of KCL IV also
given. NL CXR and abdominal series. Care
transferred to next shift physician
REAL CASES
EKG: NSR
 CBC…WBC [12.6]
 U/A…glucose [250], trace blood & protein
 CMP…K+ [2.6], glucose [220]
 CPK-MB, troponin I, lipase and amylase all NL

REAL CASE
Re-examined at least two documented times by
ED physician with BP’s of 190/119 & 194/110.
 Also received 20 mg enalapril and clonidine 0.2
mg po. Phenergan 12.5 mg IV administered.
 Arrived at 5:30 am and was D/C’ed at 9:20am
 Dx’ed : “Volume depletion, vomiting,
hypertension and hypokalemia”…asked to f/u
with PCP.

REAL CASE

Issues with care? Any errors?
REAL CASE
Later that same day husband reported that
when he returned from work at 6:00 pm he
found his wife having “vomited everywhere”
with continued N & V.
 She also c/o a severe HA
 Returns to ED via EMS where CT brain shows a
large posterior fossa hemorrhage

REAL CASE

She was intubated and mechanically ventilated.
On the 3rd day after evaluation by neurology
and the neurosurgical consultants she was
declared brain dead and the family agreed to
organ donation
SURGICAL ADVICE
ADE
•
The reported incidence of inpatient
medication errors varies widely,
depending on the detection method used,
but is estimated to range from 0.012 to
1.4 errors per patient admission.
A recent prospective study found that
524 (15.8%) of 3322 patients who were
followed through their hospitalization had
at least 1 ADR. [7]
[6]
•
–
[6] Arch Intern Med. 1997; 157: 1569-76 [7] PLoS One 2009: 4: e4439
ADE
Initiation of the causative drug as a new
inpatient therapy was responsible for 602
(82.1%) of the ADRs that occurred.
 The strongest predictor of a patient
experiencing an ADR was the number of
medications received.
 Additional risk factors for ADRs included older
age and female sex.

SBAR
NURSING SHORTAGES
•
•
Recent nursing shortages have decreased
the nurse: patient ratio.[8,9]
It expected to worsen, as registered nurse
positions constitute the largest portion of
projected growth in any industry, and
enrollment and graduation in nursing
education programs will not satisfy the
industry's demand.[ 10.11]
–
Americans for Nursing Shortage Relief. Testimony regarding fiscal year 2007 appropriations for Title VIII. Nursing
Workforce Development Programs. www.gpo.gov/fdsys/pkg/CHRG-109shrg59104229/pdf/CHRG109shrg59104229.pdf (accessed 2011 May 13) [9] U.S. Department of Health and Human Services. Projected
supply, demand, and shortages of registered nurses: 2000–2020.
www.ahcancal.org/research_data/staffing/Documents/Registered_Nurse_Supply_Demand.pdf (accessed 2011
May 13)
[8]
NURSING SHORTAGES
•
•
Increased staffing requirements have been
correlated with increased nursing errors,
including those involving medications.
Factors most often cited by medical
residents as contributing to poor quality
handoffs were incomplete reports of all
major active issues, handoffs not being
face-to-face, frequent interruptions, and no
opportunity for the recipient of the handoff
to ask questions.
…..DISCHARGE
More than 60% of patients had three or more
changes in their drug regimen during their
hospital stay.
 A large number of drug changes are for
conditions other than the disease that
precipitated the hospital admission.

…..DISCHARGE
•
The most common types of discrepancies
are the omission of medications and
incomplete or inaccurate prescriptions..305
likely to cause harm or discomfort.
Medications started as inpt. therapy, such
as PPI for stress-ulcer prophylaxis or
hypnotics for insomnia, are often continued
inappropriately at D/C, adding to the
patient's medication burden.[13,14]
[12]
•
–
[13,14]
Ann Pharmacother. 2007; 41:1611–6 , J Clin Pharm Ther. 2002; 27:93–7
ADE…..READMISSION
ADEs are the most common adverse
event experienced by patients after
hospital discharge, occurring in
approximately 10–20% of patients.
 The overall risk for an ADE post discharge
in one analysis was 4.4% for every drug
alteration or change.[15]


[15] Ann
Intern Med. 2004; 164:545–50
ADE…..READMISSION

One intervention proven to reduce ADEs is
discharge reconciliation and patient education
by a pharmacist. This intervention has been
shown to positively affect predischarge and
postdischarge medication errors and adverse
events, resulting in decreased hospital
readmissions and increased patient
satisfaction.[18,19]]

[18] Am
J Geriatr Pharmacother. 2004; 2:257–64 [19] Hosp Pharm. 2008; 43:121–6.
CONCLUSION
•
Patients no longer have one physician,
hospital, or pharmacist; their movement
through different health care entities is as
dynamic as the constant refinements to our
own systems. Lack of communication and
consistent methodologies for tracking
patients, their health status, and all
medications are root causes for many
adverse events and medication errors that
jeopardize patients' health.
CONCLUSION
•
Despite the existence of National Patient
Safety Goals for proper medication
reconciliation, transfer documentation,
discharge, and follow-up, there are no
universally recommended standards for
these tasks. Computerized prescribing,
documentation, medication review, and
reconciliation carry with them the
potential to increase patient safety across
the continuum of care.
THEORY

Swiss cheese: all aspects of health care have
layers with holes and barriers that let error
through and stop it from reaching the next
layer.
BLUNT AND SHARP END MODEL
Sharp End>>>>>> Patient

Doctor
Administration

Formal Procedures
 Messy blunt end>> Rules and Regulations

Informal Procedures
 Policies & procedures/ resource allocation


SWISS CHEESE
Potential for latent failure:
 Understaffed RNs at a facility dispensing too
many medications/ distracted
 No bar coding system
 No pharmacist to review medications
 Patient asks what he is receiving...last
opportunity to capture an error

IMPORTANT CONSEQUENCES

The last person to touch the patient can’t
take all the credit, nor all the blame, since
he or she is not the whole pyramid or all the
cheese.
IMPORTANT CONSEQUENCES
The last person to touch the patient can’t take
all the credit, nor all the blame, since he or she
is not the whole pyramid or all the cheese
 Don’t kill the messenger! Virtually all system
accidents are due to faulty processes, not bad
people----reward reporters.
 Last layer injury prevention are success stories
so;

IMPORTANT CONSEQUENCES

Need to know how the institutional pyramid is
built along blunt and sharp end----need front
line folks to report and improve the system
20 TIPS TO PREVENT MEDICAL ERRORS
Agency for Healthcare Research and Quality (AHRQ)
ADVICE TO PATIENTS
Taking Ownership of Your Health
20 TIPS TO PREVENT MEDICAL ERRORS


Make sure that all of your doctors know about every medicine you are
taking.
This includes prescription and over-the-counter medicines and dietary
supplements, such as vitamins and herbs.
Bring all of your medicines and supplements to your doctor visits.
"Brown bagging" your medicines can help you and your doctor talk about
them and find out if there are any problems. It can also help your doctor
keep your records up to date and help you get better quality care.

Make sure your doctor knows about any allergies and adverse reactions you
have had to medicines.
This can help you to avoid getting a medicine that could harm you.
20 TIPS TO STAY SAFE


When your doctor writes a prescription for you, make sure you can read it.
If you cannot read your doctor's handwriting, your pharmacist might not be
able to either.
Ask for information about your medicines in terms you can understand—
both when your medicines are prescribed and when you get them:






What is the medicine for?
How am I supposed to take it and for how long?
What side effects are likely? What do I do if they occur?
Is this medicine safe to take with other medicines or dietary supplements I am taking?
What food, drink, or activities should I avoid while taking this medicine?
When you pick up your medicine from the pharmacy, ask: Is this the
medicine that my doctor prescribed?
WHAT YOU CAN DO TO STAY SAFE



If you have any questions about the directions on your medicine labels, ask.
Medicine labels can be hard to understand. For example, ask if "four times
daily" means taking a dose every 6 hours around the clock or just during
regular waking hours.
Ask your pharmacist for the best device to measure your liquid medicine.
For example, many people use household teaspoons, which often do not
hold a true teaspoon of liquid. Special devices, like marked syringes, help
people measure the right dose.
Ask for written information about the side effects your medicine could
cause.
If you know what might happen, you will be better prepared if it does or if
something unexpected happens.
HOSPITALIZATION ADVICE



If you are in a hospital, consider asking all health care workers who will
touch you whether they have washed their hands.
Handwashing can prevent the spread of infections in hospitals.
When you are being discharged from the hospital, ask your doctor to explain
the treatment plan you will follow at home.
This includes learning about your new medicines, making sure you know
when to schedule follow-up appointments, and finding out when you can get
back to your regular activities.
It is important to know whether or not you should keep taking the medicines
you were taking before your hospital stay. Getting clear instructions may
help prevent an unexpected return trip to the hospital.


If you are having surgery, make sure that you, your doctor, and your surgeon
all agree on exactly what will be done.
Having surgery at the wrong site (for example, operating on the left knee
instead of the right) is rare. But even once is too often. The good news is
that wrong-site surgery is 100 percent preventable. Surgeons are expected
to sign their initials directly on the site to be operated on before the surgery.
If you have a choice, choose a hospital where many patients have had the
procedure or surgery you need.
Research shows that patients tend to have better results when they are
treated in hospitals that have a great deal of experience with their condition.
OTHER STEPS




Speak up if you have questions or concerns.
You have a right to question anyone who is involved with your care.
Make sure that someone, such as your primary care doctor, coordinates
your care.
This is especially important if you have many health problems or are in the
hospital.
Make sure that all your doctors have your important health information.
Do not assume that everyone has all the information they need.
Ask a family member or friend to go to appointments with you.
Even if you do not need help now, you might need it later.
OTHER STEPS



Know that "more" is not always better.
It is a good idea to find out why a test or treatment is needed and how it can
help you. You could be better off without it.
If you have a test, do not assume that no news is good news.
Ask how and when you will get the results.
Learn about your condition and treatments by asking your doctor and nurse
and by using other reliable sources.
For example, treatment options based on the latest scientific evidence are
available from the Effective Health Care Web site. Ask your doctor if your
treatment is based on the latest evidence.
TO ERR IS HUMAN

“I claim to be a simple individual liable to err like any
other fellow mortal. I own, however, that I have
humility enough to confess my errors and to retrace
my steps.”

Mahatma Gandhi
TO FORGIVE IS DIVINE

“It is the highest form of self-respect to admit our
errors and mistakes and make amends for them. To
make a mistake is only an error in judgment, but to
adhere to it when it is discovered shows infirmity of
character. “

Dale E. Turner