Medical Students and Medical Students and Medical ErrorsMedical Errors

ICC 7001ICC 7001April 20, 2009April 20, 2009

Wendy Madigosky MD, MSPHWendy Madigosky MD, MSPHShelly Dierking, CEO Patient Shelly Dierking, CEO Patient Safety Education PartnershipSafety Education Partnership

ObjectivesObjectives

1) 1) Have an advanced understanding of Have an advanced understanding of the occurrence of medical error in the the occurrence of medical error in the clinical environment clinical environment

2)2) Have an appreciation for the personal Have an appreciation for the personal impact of medical errorsimpact of medical errors

3)3) Be aware of the student role in Be aware of the student role in improving patient safetyimproving patient safety

4)4) Be familiar with local hospital efforts to Be familiar with local hospital efforts to reduce error and improve quality of reduce error and improve quality of carecare

Of course, we want patients to be Of course, we want patients to be safe!safe!

► Implicit in providing quality health care Implicit in providing quality health care is ensuring the care is safe.is ensuring the care is safe.

►No health care provider sets out in the No health care provider sets out in the morning to see if they can make the morning to see if they can make the care they provide more dangerous.care they provide more dangerous.

►However, the statistics suggest that However, the statistics suggest that despite the intrinsic role of safety in despite the intrinsic role of safety in quality care, we fall short of the mark.quality care, we fall short of the mark.

►How many of you have experienced a medical error—as a patient or family member?

►In your training thus far, how many of you have seen something that shouldn’t happen again?

Working definitions…Error Failure of a planned action to be

completed as intended (e.g. error of execution) or the use of a wrong plan to achieve an aim (e.g. error of planning).

Adverse Event

An injury caused by medical management rather than the underlying condition of the patient.

Near Miss

An event or situation that could have resulted in an accident, injury, or illness, but did not, either by chance or through timely intervention. Also referred to as a close call.

Sentinel Event

An unexpected occurrence or variation involving death or serious physical or psychological injury or the risk thereof.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press, 1999.

Epidemiology of Medical Epidemiology of Medical ErrorsErrors

Adverse Events in Retrospective Studies

►New York State, 1984 3.7% of hospitalizations 69% caused by errors

►Colorado and Utah, 1992 2.9% of hospitalizations 6.6% mortality

Adverse Events inObservational Studies

►Chicago teaching hospital, 1997 45.8% patients on general surgical units 18% produced disability

►Israeli medical-surgical ICU, 1995 1.7 errors/patient/day

What does a 2-4% adverse event rate mean?

► 0.1% Rate: 1 hour of unsafe drinking water every month 2 unsafe plane landings per day at O’Hare Airport in

Chicago 16,000 pieces of mail lost every hour 22,000 checks deducted from the wrong bank account

each hour 20,000 incorrect prescriptions every year 500 incorrect operations each week 50 babies dropped at birth every day

► Multiply by 20-40 to reflect a 2-4% error rate!

November 1999

►33.6 million admissions to U.S. hospitals in 1997

►44,000 - 98,000 deaths per year as a result of medical errors

Top Causes of Death in US: 2006

1. Heart disease: 631,6362. Malignant neoplasm: 559,8883. Cerebrovascular disease: 137,1194. Chronic, lower respiratory disease:

124,583 5. All accidents: 121,5996. Diabetes: 72,4497. Alzheimer’s: 72,4328. Influenza and pneumonia: 56,3269. Nephritis/nephrosis: 45,34410. Septicemia: 34,234

www.cdc.gov/nchs

Deaths from Adverse EventsDeaths from Adverse Events

►More common than:More common than: Breast CancerBreast Cancer Motor Vehicle AccidentsMotor Vehicle Accidents AIDSAIDS

►44,000-98,000 estimate does 44,000-98,000 estimate does NOTNOT include deaths from ambulatory sites include deaths from ambulatory sites (nursing homes, home-health, office-(nursing homes, home-health, office-based practices)based practices)

What does this have to do with What does this have to do with me? me?

►Medical errors are a significant Medical errors are a significant cause of morbidity and mortalitycause of morbidity and mortality

►You are going to make mistakes, You are going to make mistakes, witness errors, and participate in witness errors, and participate in unsafe careunsafe care

Everyone makes mistakes, Everyone makes mistakes, but…but…

►Errors more common if:Errors more common if: Inexperienced providersInexperienced providers New techniques usedNew techniques used

►Adverse events more common if:Adverse events more common if: Patient age >64Patient age >64 Invasive proceduresInvasive procedures Complex illnessesComplex illnesses Longer hospitalizationLonger hospitalization

Weingart SN, Wilson RMcL, Gibberd BH. Epidemiology of medical error. BMJ 320;774-777.

Intern and Resident Mistakes Intern and Resident Mistakes ►114 respondents (36% interns, 64% 114 respondents (36% interns, 64%

residents)residents)►Types of errors respondents admitted Types of errors respondents admitted

toto Diagnosis (33%)Diagnosis (33%) Prescribing and dosing (29%)Prescribing and dosing (29%) Evaluation and treatment (21%)Evaluation and treatment (21%)

►OutcomesOutcomes 90% reported significant adverse patient 90% reported significant adverse patient

outcomes, including deathoutcomes, including deathWu A, Folkman S, McPhee SJ, Lo B. Do House Officers Learn From Their Mistakes? JAMA 1991;265:2089-2094.

Types of Error Causes of Errors

• Diagnosis• Evaluation• Treatment• Prescribing• Procedures• Communication

• Factual ignorance• Faulty judgment• Hesitation• Breaks in

concentration• Inexperience• Job overload• Fatigue• SYSTEM FLAWS

Basic Science of Medical Errors

►Medical knowledge►Communication►Teamwork

►Human factors engineering►Cognitive science►Quality Improvement

Demonstration: Stroop Effect

Row 1

Row 2

Row 3

Now, State the Color of the Text as Fast as You

Can…

Red

Red

Red Blue

Blue

BlueYellow

Yellow

Yellow

Green

Green

Green

Row 1

Row 2

Row 3

Again, State the Color of the

Text as Fast as You Can…

Red

Red

Red Blue

Blue

BlueYellow

Yellow

Yellow

Green

Green

Green

Row 1

Row 2

Row 3

“Tell the nursing

student to attach the

oxygen mask and tubing to

the green spigot”

For further info, see http://faculty.washington.edu/chudler/words.html#seffect J. Ridley Stroop (1935) Studies of Interference in Serial Verbal Reactions. Journal of Experimental Psychology, vol 18, 643-662

Patient Safety Correlation

Make sure to use the correct color Adaptor!?

Better

Weaker vs. Stronger Remedy

CommunicationTeamwork

Human Factors Engineering and Your World

►Anesthesiology Design of alarms, monitors, and safety

systems

►Emergency Medicine Design of decision-making tools and

monitoring

►Surgery Design of hand tools and visualization

devices (laparoscopy)

Video Demo

►Count the number of passes made between basketball players wearing white T-shirts

►Write down your answer (quietly – not a group effort)

►At the end, I will ask for answers

Cognitive theory► Cognition is how people reason and make

decisions► Providers may use deduction, induction or

intuition to solve problems► Novices lean toward deduction and

exhaustive work-ups► Experts have more knowledge and use

logic, probability and especially intuition

Coderre Med Ed 2003

Diagnostic Cognitive Errors/Solutions

► Aggregate bias► Anchoring► Availability bias► Confirmation bias► Diagnosis

momentum► Gambler’s fallacy► Sutton’s slip

► Develop insight► Consider

alternatives► Metacognition► Decrease reliance

on memory► Simulation► Minimize time

pressures

Croskerry: Acad Med, Volume 78(8).August 2003.775–780

Where do I learn more about this?

► Piecemeal within curriculum► Self-guided study► IHI Open School

Free courses in patient safety, human factors engineering, quality improvement, teamwork/communication

http://www.ihi.org/IHI/Programs/IHIOpenSchool/ UCD Chapter now formed--if interested in helping to lead

within AMC contact Dr. Madigosky► AHRQ web M&M: www.webmm.ahrq.gov

Web-based medical journal showcasing patient safety lessons drawn from actual cases involving medical errors

5 cases per month from medicine, surgery-anesthesia, OB/GYN, pediatrics, psychiatry

Commentaries from experts

S. Dekker, The Field Guide to Human Error Investigations

““Bad Apple” TheoryBad Apple” Theory

►Our systems are good and would be Our systems are good and would be safe were it not for the actions of a safe were it not for the actions of a few people who behave erratically.few people who behave erratically.

► If an error occurs the task is to find out If an error occurs the task is to find out who did it and to take the necessary who did it and to take the necessary steps so they do not do it again.steps so they do not do it again.

S. Dekker, The Field Guide to Human Error Investigations

““New” View of Human ErrorNew” View of Human Error

►An error is a symptom of systemic An error is a symptom of systemic factors in the environment which factors in the environment which create the circumstances for an error create the circumstances for an error to happen to happen

S. Dekker, The Field Guide to Human Error Investigations

Two views of human errorTwo views of human errorOldOld

► Human error is a Human error is a cause of accidentscause of accidents

► To explain failure To explain failure you must seek you must seek failurefailure

► You must find You must find people’s inaccurate people’s inaccurate assessments, assessments, wrong decisions wrong decisions and bad judgmentsand bad judgments

NewNew► Human error is a Human error is a

symptom of deeper symptom of deeper problems inside a problems inside a systemsystem

► To explain failure do not To explain failure do not seek where people seek where people went wrongwent wrong

► Instead, find how Instead, find how people’s assessments people’s assessments and actions made sense and actions made sense at the time, given the at the time, given the circumstances that circumstances that surrounded them.surrounded them.

Our Medical Culture►Taught in an authoritarian manner

with a sense of absolute right/wrong►Medicine is infallible; we should be

perfect►There is always one right answer►Confidence equals competence►Error equals incompetence, negligence

or laziness►Error carries shamePilpel D, Schor R, Benbassat J. Barriers to acceptance of medical error: the case for a teaching programme. Med Educ. 1998;32(1):3-7.

Awareness and Shame May be Largest Hurdles

► 1999 Survey at VA and Private Healthcare Organizations Only 27% Agreed that Errors were a Serious

Problem 49% “Ashamed” by Error

► Blendon et al. (2003) in NEJM A majority of surveyed physicians thought that

individual health care providers were more likely to be responsible for medical errors than hospitals

Medical Socialization

• The ‘truth’• Baskin Robbins• Discipline specific games• Critical thinking

Typical Responses

• Denial• Discounting• Distancing

• Mizrahi T. Soc. Sci. Med, 1984. Vol 10 No 2 pp 135-146.

• Guilt, fear, anger, embarrassment, humiliation, anxiety, depression, self-doubt, rumination about event, excessive concern, overwork, anguish

• Christensen JF et al. JGIM, 1992. Vol 7 pp424-431

Resident Responses

• Remorse• Anger at selves• Guilt• Inadequacy• Fear• Psychological impact

Wu A, et al. JAMA, April 24, 1991—Vol. 265, No. 16, Pg 2089-2094

Resident Coping Strategies

• Problem focused• Acceptance of responsibility• Consultation to understand the nature of

the mistake• Consultation to correct the mistake• Planned problem solving (extra-training)

Resident Coping Strategies

• Emotion-focused• Obtaining social support• Disclosure to colleague, friend or spouse• Disclosure to patient• Reframing mistake

Resident Changes in Practice

• Constructive• Increased information seeking• Increased vigilance• Improved self-pacing• Improved communication• Supervising others closely

Resident Changes in Practice

• Defensive• Avoiding similar patients• Being unwilling to discuss the error• Ordering additional but unnecessary tests

Bottom Line

• To have constructive responses to medical errors:• Accept responsibility for the error• Know that it may be emotionally stressful• Disclose the error to others• Use the error as an educational tool

Beyond Blame

Barriers to Patient Safety

1. Medicine views errors as failings that deserve:

Blame and shame Corrective actions focusing on individuals

2. Lack of awareness

3. No blood no foul philosophy Many in health care ignore or downplay

near misses, resulting in a missed learning opportunity

Should there be a blame free environment?

►Not necessarily: In the VA, intentionally unsafe acts are

excluded from safety Without individual accountability you

cannot have safety or quality►However, the system should be

analyzed to look for problems before concluding that it was the “fault” of an individual

Person vs. System Approaches► Person approach

Focus on individuals Blaming individuals for

forgetfulness, inattention, or carelessness, poor production

Methods: disciplinary measures, threat of litigation, retraining, blaming and shaming

Target: Individuals

► System approachFocus on the conditions under which individuals work

Building defenses to avert errors/poor productivity or mitigate their effects

Methods: creating better systems

Targets: System (team, tasks, workplace, organization)

Reason J. Human error: models and management. BMJ 2000;320:768-770.

Identifying System Issues

► Communication Issues Handoffs Standardization of communication Methods of documentation Communication between disciplines or

across power gradients► Education or Training Issues► Equipment Issues► Staffing Issues► Fatigue or Scheduling Issues► Policy Issues

The The Swiss CheeseSwiss Cheese Model Model (Reason, 1991)(Reason, 1991)

Environmental

IndividualTeam

Profession

AdverseEvent

Defenses

Lack of Procedures

Punitive policies

Mixed Messages

Production Pressures

Zero fault tolerance

Sporadic Training

Attention Distractions

Clumsy Technology

Deferred Maintenance

Policies/Procedures

Policies/Procedures

Equipment

Triggers

Systems Thinking:Principles and Concepts

►Interdependencies►Structure drives behavior►Cause & effect are separated by time

& space►Any change in a system has

unintended consequences

Designing Systems for Safety

►Simplify processes Reduce hand-offs Make workplace user-friendly

►Reduce variation Standardize processes Reduce reliance on memory and vigilance

►Collaborate and improve communication Physicians, nurses, NPs, PAs, pharmacists... Patients and their families

Safe Care

►Culture promotes systemic change rather than individual blame

►Mechanisms to report near misses/errors►Redundancy within system►Well developed communication systems►Re-engineering of work-flow and

equipment

“Screaming at a system is a very interesting comment on

the screamer, but tells us nothing at all about the

system.”

Donald Berwick, MD, MPP

Why Do We Think the Systems Approach Will Work?

►Aviation Experience – 400% reduction in aircraft accidents by utilization of root cause analyses and crew safety training.

►We are now using aviators to train health care workers in patient safety.

Why Do We Think the Systems Approach Will Work?

►Anesthesia Experience – Over the last 20 years, anesthesia deaths have been reduced to 1/20th the prior rate. Interventions include: Standardization of anesthesia machines;

re-engineering to prevent O2 cut-offs Reduced resident work hours End-tidal CO2 monitors Pulse oximetry

Gwande, A. Complications; Metropolitan Books, 2002

The new view of errors from the The new view of errors from the hospital/health system hospital/health system

perspectiveperspective►The public has increasing attention on The public has increasing attention on

just how safe they are when they just how safe they are when they come for carecome for care

►Traditional methods of identifying and Traditional methods of identifying and dealing with mistakes don’t seem to dealing with mistakes don’t seem to work wellwork well

►Borrowing from other industries and Borrowing from other industries and from fields like human factors from fields like human factors engineeringengineering

►Mandates to use “new” view methods Mandates to use “new” view methods by JCAHO and othersby JCAHO and others

Right now both views of Right now both views of error co-exist in many error co-exist in many hospital and practice hospital and practice

settings –not necessarily settings –not necessarily happily.happily.

Hospitals are now mandated Hospitals are now mandated to do “new view” analyses to do “new view” analyses

of adverse eventsof adverse events►Tool’s includeTool’s include

Mandatory Adverse Event reportingMandatory Adverse Event reporting Root Cause Analysis (RCA)Root Cause Analysis (RCA) Failure Modes and Effects Analysis Failure Modes and Effects Analysis

(FMEA)(FMEA) Reporting of near-misses through Reporting of near-misses through

voluntary reporting systems (e.g. voluntary reporting systems (e.g. Patient Safety Net)Patient Safety Net)

UCH Safety/Quality Initiatives ► Hand Hygiene (100% compliance of foaming in/out)► Hand Off Communication (during transitions)► Medication Reconciliation (every visit and transitions)► Critical Test Reporting (alerts to providers)► Core Measures (pre-printed order sets) ► Pre-printed discharge instructions (AMI, CHF, Pneumonia,

Surgical Site Infections) ► Signing, timing and dating all orders and progress notes► Universal Protocol (‘time outs’, H&P available/reviewed) ► Central Line Infection Prevention (full barrier precautions,

checklist completion)► MET = Medical Emergency Team (‘rapid response team’)► Disease specific inter-professional teams: Stroke team,

Diabetes etc.Sue West, RNAssistant Vice Chancellor, Professional Risk Management Director, UCH Clinical Excellence & Patient Safety Director, Infection Control

UCH Safety Culture

►On-going improvement 2009 AHRQ Safety Culture survey

►Areas to work on Patient Safety Net reporting Staffing/workload concerns Punitive culture concerns Disruptive behavior issues Physician accountability.

UCH Insider: Volume 2, Issue 21Through April 27, 2009

Website for Additional Information on UCH Quality

Services:http://iamaze.uch.ad.pvt/quality/index.htm

University of Colorado Hospital

► Professional Risk Management Department– Sue West, Assistant Vice Chancellor

► To report a “high level” adverse event call: (303)724-7475

► Use Patient Safety Net at UCH for everything else. Icon on UCH desktop.

► Residents/fellows serve on the Risk Management Committee at UCH and on the board of the School’s Self-Insurance Trust.

The Children’s Hospital

► Patient Safety Leadership Teresa Fisher, Patient Safety Specialist Daniel Hyman, Chief Quality Officer Jeanne Crane, Risk Manager

► To report an adverse event: QSRS (voluntary reporting system)  Icon on TCH intranet

► Residents involved with RCAs when they were involved in the care of patients with adverse outcome. All serious outcomes and JCAHO sentinel events get formal RCA.

VA Hospital

►Patient Safety Officer – Jeriann Ascione

►To report an adverse event (303)393-5223

►National voluntary reporting system. ►RCAs are done by ad hoc committees.

Supportive of residents and fellows being involved but scheduling is a problem due to commitment over several weeks.

Denver Health

► Risk Management Department Dave Kvapil, Director

► To report an adverse event: (303)436-7075

► Risk Management staff do RCAs of all reportable adverse events and JCAHO sentinel events

► Follow up on Patient Safety Net reports of near misses as time permits

► No professionals-in-training involved in the RCA process

So what can I do as a medical student?

►Observe►Ask►Advocate►Report►Reflect

Take Home Points

► Lapses in safety include errors, adverse events and near misses

► Medical errors are frequent and significant threats to safe and quality health care

► A systems approach is more desirable than the blame/shame approach in improving safety

► The culture of medicine has led to barriers in improving patient safety but hospitals are working hard to implement safety/quality processes

► Medical students have a dual role: to learn about safety/quality and to be a part of safety culture and improvement activities

AcknowledgementsAcknowledgements

► University of Missouri-ColumbiaUniversity of Missouri-Columbia Quality and Patient Safety Education Group Quality and Patient Safety Education Group

► John Gosbee, MD MSJohn Gosbee, MD MS VA National Center for Patient SafetyVA National Center for Patient Safety Patient Safety Curriculum GroupPatient Safety Curriculum Group

Fun Patient Safety Resource…

►www.webmm.ahrq.gov Web-based medical journal showcasing

patient safety lessons drawn from actual cases involving medical errors

5 cases per month from medicine, surgery-anesthesia, OB/GYN, pediatrics, psychiatry

Commentaries from experts