Download - Medication errors and patient safety Vic Vernenkar, D.O. Department of Surgery St. Barnabas Hospital
Medication errors Medication errors and patient safetyand patient safety
Vic Vernenkar, D.O.Vic Vernenkar, D.O.Department of SurgeryDepartment of SurgerySt. Barnabas HospitalSt. Barnabas Hospital
Quality in HealthcareQuality in Healthcare
Begins with ensuring patient safetyBegins with ensuring patient safety
Patient safetyPatient safety
Freedom from injury or illness resulting from Freedom from injury or illness resulting from the processes of healthcarethe processes of healthcare
Healthcare errorsHealthcare errors
Failure to diagnose / incorrect diagnosisFailure to diagnose / incorrect diagnosis Failure to utilise or act on diagnostic Failure to utilise or act on diagnostic
teststests Inappropriate use or outmoded Inappropriate use or outmoded
diagnostic tests / treatmentsdiagnostic tests / treatments Failure to monitor or provide follow-upFailure to monitor or provide follow-up Wrong site surgery, Wrong site surgery, medication errorsmedication errors Transfusion mistakesTransfusion mistakes
Healthcare errorsHealthcare errors
Nosocomial infectionsNosocomial infections Patients fallsPatients falls Pressure soresPressure sores Phlebitis associated with intravenous Phlebitis associated with intravenous
lineslines Restraint related strangulationRestraint related strangulation Preventable suicidesPreventable suicides Failure to provide prophylaxisFailure to provide prophylaxis
How big is the problem?How big is the problem?
USAUSA errors by HCWs affect about 3-4% patientserrors by HCWs affect about 3-4% patients
• mean of 7% ADEsmean of 7% ADEs• >7,000 ADE deaths / year>7,000 ADE deaths / year• 2 million nosocomial infections / year2 million nosocomial infections / year• average ICU patient experiences almost 2 errors per dayaverage ICU patient experiences almost 2 errors per day
each year, 44,000 - 98,000 deaths due to medical each year, 44,000 - 98,000 deaths due to medical errors errors
annual cost of medical errors: US$29 billionannual cost of medical errors: US$29 billion
Medication errorsMedication errors
Prescribing errorsPrescribing errors
Administration errorsAdministration errors includes failure to monitor drug levels and includes failure to monitor drug levels and
side effects of treatmentside effects of treatment
Medication errorsMedication errors
Rate of 3.99 per 1000 medication orders (Albany, NY, Rate of 3.99 per 1000 medication orders (Albany, NY, USA)USA)
a third had potential to cause adverse eventsa third had potential to cause adverse events
Common factorsCommon factors failure to take account of declining renal/hepatic functionfailure to take account of declining renal/hepatic function failure to check for possible allergic responsesfailure to check for possible allergic responses using wrong drug name or means of administrationusing wrong drug name or means of administration miscalculation of dosagemiscalculation of dosage prescribing an unusual critical frequency of dose prescribing an unusual critical frequency of dose
Lesar et al. Factors related to medication errors. JAMA 1997; 277: 312-7
Why did it happen?Why did it happen?
Technology e.g. infusion pumpsTechnology e.g. infusion pumps Many care-giversMany care-givers High acuity of illness / injuryHigh acuity of illness / injury Environment prone to distractionEnvironment prone to distraction Time-pressured, need to make quick Time-pressured, need to make quick
decisionsdecisions High volume, unpredictable patient loadHigh volume, unpredictable patient load
Key reasonsKey reasons
Patients are more at risk than non-patientsPatients are more at risk than non-patients Medical interventions are, by their nature, Medical interventions are, by their nature,
high-risk procedures - small error marginshigh-risk procedures - small error margins Medicine remains an inexact, hands-on Medicine remains an inexact, hands-on
endeavourendeavour
FactsFacts
Often it is the best people who make the Often it is the best people who make the worst errorsworst errors
About 90% of errors are not culpableAbout 90% of errors are not culpable But some people knowingly adopt But some people knowingly adopt
behaviors more likely to produce error - behaviors more likely to produce error - substance abuse, long working hourssubstance abuse, long working hours
Organisational accident modelOrganisational accident modelOrganisational
and corporate culture
Contributoryfactors
influencingclinical practice Task Defence barriers
Accidentor
incident
Managementdecisions andorganisational
processes
Errorproducingconditions
Violationproducingconditions
Errors
Violations
James T Reason
Lessons from pastLessons from past
Problems often formally recognised when there Problems often formally recognised when there is a is a major incidentmajor incident
Methodologies for Methodologies for organisational analysisorganisational analysis not not well developedwell developed
Short-term corrective action Short-term corrective action not well sustainednot well sustained Problems in dealing with Problems in dealing with aftermathaftermath of service of service
failure - grievance of victims and their familiesfailure - grievance of victims and their families
Failure in standard of care
Detect
Analyse
Take corrective action
Sustain corrective action
Deal with consequences
Prevent similar problem
Cycle of preventionCycle of prevention
RecommendationsRecommendations
Leadership priorityLeadership priority
Clear organisational commitment to Clear organisational commitment to patient safety (infrastructure and patient safety (infrastructure and resources)resources)
No-blame cultureNo-blame culture
Culture of safetyCulture of safety
Integrated pattern of behaviourIntegrated pattern of behaviour
Underlying philosophy and valuesUnderlying philosophy and values
Continuos search to minimise hazards and Continuos search to minimise hazards and patient harmpatient harm
Acknowledges high risk, error prone Acknowledges high risk, error prone naturenature
Widespread shared acceptance of Widespread shared acceptance of responsibility for risk reductionresponsibility for risk reduction
Open communication about safety Open communication about safety concerns, non-punitive environmentconcerns, non-punitive environment
Reporting of errors and safety concernsReporting of errors and safety concerns
Culture of safetyCulture of safety
Learns from errorsLearns from errors
Accountability for patient safetyAccountability for patient safety
Organisational structure, processes, Organisational structure, processes, goals and rewards aligned with goals and rewards aligned with improving patient safetyimproving patient safety
Culture of safetyCulture of safety
Strategy 1: teamsStrategy 1: teams
Implement known safe Implement known safe practicespractices
Design work so that it is Design work so that it is easy to do it right and easy to do it right and hard to do it wronghard to do it wrong
Reduce reliance on Reduce reliance on memorymemory
Less stepsLess steps ConstraintsConstraints Protocols and checklistsProtocols and checklists
Clinical PathwaysClinical Pathways
Care process modelsCare process models
Teams - lessons from the navyTeams - lessons from the navy Members monitor each other’s performance and Members monitor each other’s performance and
stepped in to to help out. stepped in to to help out. TRUSTTRUST was an implicit was an implicit part of this.part of this.
Giving and receiving feedback was norm for all Giving and receiving feedback was norm for all team members. team members. Understanding each other’s Understanding each other’s rolerole is important part. is important part.
CommunicationCommunication was made real: senders was made real: senders checked their messages were received as checked their messages were received as intended.intended.
Teamwork and team leadershipTeamwork and team leadership
Good teams do not develop on their ownGood teams do not develop on their own organisational culture of welcoming openness organisational culture of welcoming openness
and monitoring changes that resultand monitoring changes that result
Good team leadership is essentialGood team leadership is essential development is vital across organisationdevelopment is vital across organisation
Hospital team activitiesHospital team activities
Improving information accessImproving information access hospital teams redesigned medication administration recordshospital teams redesigned medication administration records
Standardising and simplifying medication proceduresStandardising and simplifying medication procedures teams worked on high risk and high error-potential drugsteams worked on high risk and high error-potential drugs
Restricting physical access to potentially lethal drugsRestricting physical access to potentially lethal drugs chemotherapy drugs, concentrated KCl, NaClchemotherapy drugs, concentrated KCl, NaCl
Educating clinical staff about medicationsEducating clinical staff about medications to assess knowledge deficiencies, drug knowledge, awareness to assess knowledge deficiencies, drug knowledge, awareness
for potential for errorfor potential for error
Silver et al. Reducing medication errors in hospitals: a peer review organisationcollaboration. J Qual Improvement 2000; 26: 332-40
Recognise effect of Recognise effect of fatigue on fatigue on performanceperformance
Education and Education and training for safetytraining for safety
TeamworkTeamwork Reduce known Reduce known
sources of confusionsources of confusion
Strategy 2: education Strategy 2: education
AwarenessAwareness
EducationEducation
Training and supervisionTraining and supervision
Training in organisational aspects of careTraining in organisational aspects of care medical training focuses on diagnosis and medical training focuses on diagnosis and
management of individualsmanagement of individuals
Training in skills of risk managementTraining in skills of risk management understanding of inevitability of human errorunderstanding of inevitability of human error factors associated with errors, mistakes and near factors associated with errors, mistakes and near
missesmisses appropriate checking behaviour, safe handoverappropriate checking behaviour, safe handover team workteam work
Strategy 3: accountabilityStrategy 3: accountability
Acknowledge errorAcknowledge error ApologiseApologise Provide remedial careProvide remedial care Conduct root cause Conduct root cause
analysisanalysis Fix system or process Fix system or process
problemsproblems
Risk management Risk management systemsystem
Sentinel event teamSentinel event team
Clinical incident reporting Clinical incident reporting systemsystem
Success depends on change in cultureSuccess depends on change in culture staff must be convinced of importance of staff must be convinced of importance of
patient safetypatient safety board has to agree on “no-blame” cultureboard has to agree on “no-blame” culture systematic and strategic approach to risk systematic and strategic approach to risk
managementmanagement reporting system must produce reports that reporting system must produce reports that
are timely and informativeare timely and informative
Risk Management Risk Management System (RMS)System (RMS)
Reporting Nurse
Injured Staff
Reporting Doctor
Nurse Manager Follow-up Doctor
Head ofDepartment/ Division Chairman
Assist. Director Nursing
Dept Of Quality Management
InfectionControl
(Sharp only)
Fall Report
CEO/CMB
CMB /Administrator
Sharp ReportDoctor
Management
Sharp Report
Supervisor / Manager
Sharp Report
Sharp Report
Reporting Person
Fall ReportFall ReportFall Report
Pharmacy Manager
Medication
Error Report
Medication
Error Report
Medication
Error Report
Sharp Report Sharp Report Sharp
Report
Sharp Report
Fall Report
Sharp Report
M ed ica tio ne rro rs
C lin ica l in c id en t:m o rb id itym ro ta lity
su rg ica l in c id en t
S h a rp s in ju ry P a tien t fa lls C o m p la in ts
R M S
C at I o r C a t II?C a t I C a t II
C M B an d D Q M in fo rm edw ith in 6 H
S E T
R o o t cau se an a lys is b yap p o in ted team
R eco m m en d a tio n srep o rted to S E T
R eco m m en d a tio n sim p lem en ted ?
H O D /M an age rs m o n ito r toa ssu re co m p lian ce w ithco rrec tive ac tio n s an d
rep o rt b ack to R M
O p era tio n s in fo rm ed toim p lem en t
reco m m en d a tio n s
D Q M p resen ts f in d in gs ,reco m m en d a tio n s , su m m ary an a lys is ,
an d fo llo w -u p to R M , Q C , rep o rtsn u m b er o f even ts q u a rte rly p e r
d ep a rtm en t to Q C as p a rt o f B S C
R ep o rt w ith in vestiga tio n f in d in gsan d reco m m en d a tio n s to D iv is io n
C h a irm an
R ep o rt to C M B , C E O , an d D Q M
Y es
No
Risk Management System
Sentinel Event TeamSentinel Event Team
CEOCEO CMBCMB Administrator, NursingAdministrator, Nursing Director, QMDirector, QM Administrator, Medical BoardAdministrator, Medical Board
Sentinel Event TeamSentinel Event Team
Incident reporting, complaintsIncident reporting, complaints
Category ICategory I
SET discussionSET discussion
Appoints team to investigateAppoints team to investigate
Root cause analysisRoot cause analysis
Reviewing the processReviewing the process What happen?What happen?
How did it happen?How did it happen?
Why did it happen?Why did it happen?
What can we do differently?What can we do differently?
MOH requirementMOH requirement
Report within 7 days of knowingReport within 7 days of knowing Submit full report within 60 daysSubmit full report within 60 days De-identifyDe-identify Objective: how can we improveObjective: how can we improve
what happen, how did it happen, why did it what happen, how did it happen, why did it happen, can we do differently?happen, can we do differently?
ImpactImpact
“As evidence in support of the value of the changes madeto our processes, we observed no further fatal ADEs…..”
John Rex et al. Systematic root cause analysis of adverse drug eventsin a tertiary referral hospital. J Qual Improvement 2000; 26: 563-75
Key findings in IOM report:Key findings in IOM report:
•Errors occur because of system failures
•Preventing errors means
designing safer systems of care
To Err is Human. Institute of Medicine, 2000.Committee on Quality of Health Care in America.
IOM reportIOM report
Avoid reliance on memoryAvoid reliance on memory Use constraints or forcing functionsUse constraints or forcing functions Avoid reliance on vigilanceAvoid reliance on vigilance Simplify key processesSimplify key processes Standardise work processesStandardise work processes