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

Top worry of patient!Top worry of patient!

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

Errors are inevitable

………….but most are preventable

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

Process review and changeProcess review and change

Whose job is it?- Risk Manager?

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

Main Incident Page – Reporting Person

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

Institutional practiceInstitutional practice

CClinical risk management systemlinical risk management system PPlanlan

PProcessrocess

PPeopleeople

CCultureulture LEADERSLEADERS