Medication Errors and Patient Safety: Implementing
a Continuous Quality Assurance Program
Linda Allen, Gareth Buckley, Megan Eide, Sheri Holloway, Jude Kaufman, Chris
Sanchez, Dana Zimmel
Objectives
• Define patient safety reporting and the concept of just culture
• Differentiate between levels of patient harm • Identify common barriers to reporting • Explain structured ways that systems can be changed or implemented to reduce harm
Reasons for launching the Patient Quality and Safety Initiative
• ONE HEALTH: In alignment with UF Health goal to “strive for the highest quality, safest experience for every patient.”
• Creating a culture of patient safety is a key feature in the daily operations of human hospitals, and the UF Veterinary Hospitals has committed to do the same.
• Quality and Safety are of critical importance to the UF Veterinary Hospitals.
IDInc
• Online database system used for managing patient safety reports
• Access is from an icon on all Veterinary Hospital desktops
• Helps manage, track and trend safety events • Drives improvement
Quality and Patient Safety Journey
Mar 15 Initiated IDInc
Aug 16 AHRQ Survey
Nov 16 RCA – Order Writing
Mar 17 PQS team – rapid ID of anesthesia equipment issue
Sep 17 Hired Quality Officer
Today
• Core patient safety team • Linda Allen, Quality Officer • Dr. Gareth Buckley, Chief Medical Officer, SAH
• Dr. Megan Eide, Pharmacy Manager • Sheri Holloway, Assistant Director, SAH • Jude Kaufman, Assistant Director, LAH • Dr. Chris Sanchez, Chief Medical Officer, LAH
• Dr. Dana Zimmel, Associate Dean for Clinical Services
Culture of safety
• Everyone feels safe reporting patient adverse events
• Mistakes are approached in a fair and just manner, regardless of the severity of the outcome.
• Just Culture • Goals are designed to facilitate teamwork and improve communications
• Hierarchies are flattened • Everyone is encouraged to speak up
http://commission.org/topics/patient_safety.aspx
Reporting Algorythm
Who was harmed?
Who identified event?
Patient
Staff or Clinician
Client
Staff or Clinician
Go to IDInc and enter a PSR
*Complete Accident Investigation Report
(paper)
Go to IDInc and enter a Pt Complaint
What is a PSE/PSR?
• Patient Safety Event/ Patient Safety Report • Any event that caused actual or potential patient harm • Potential Harm may be:
• Near miss event • Require intervention to prevent harm
• Actual Harm may: • Require intervention • Increased Hospital Stay • Involve Major Harm: Death, Serious Safety Event
Question 1:
• What is a patient safety event?
Examples of PSEs – With Potential Harm
• Equipment not serviced at proper interval • Medication pulled for wrong patient but caught before
administration • Laboratory: Machine failed QC, so it was pulled
offline • Pharmacy: Caught label error prior to dispensing • Surgery: Instruments contaminated but caught
before use
Examples of PSEs – With Actual Harm
• ECC/PCW: Performed procedure on wrong dog • Anesthesia: Equine tibial fracture during recovery • Large Animal Hospital: Pump set incorrectly;
delivered lidocaine at wrong rate, horse became ataxic
• Laboratory: Incorrect test results were reported to DVM
• Pharmacy: Medication Labeled with incorrect formulation
• Surgery: Performed surgery on the wrong limb
Event Reported
Initial Review (Quality officer)
Management Investigation (Technician Manager or
Service Chief)
PQS team for further investigation
Event Reviewed and Closed
(Medical Director)
Major patient harm or repetitive event
Routine event
Management investigations
• Initially by area manager • Can re-assign if needed • Review medical record • Talk to individuals involved • Goal is to determine what happened
• Was there an error or not? • If error, how can we prevent it?
• Identify and manage system imperfection
Root cause analyses
• Comprehensive, systematic method to identify gaps in hospital systems
• Develop actions to reduce risk of sentinel events • What happened? • Why did it happen? • What can be done to prevent reoccurrence?
• Focus on systems, processes – NOT people
http://commission.org/topics/patient_safety.aspx
Hierarchy of intervention effectiveness
http://patientsafe.wordpress.com/
How do we use the information? ! Tracking and Trending such as
" The types of reports by department " The annual number of patient harm events by month " Tabulated medication errors by medication " Scholarly initiatives for residents and staff
! Identifying common problems across the organization such as " Treatments to the wrong patient due to same name " Missing forms or checklists " Most frequent medication errors " Equipment maintenance log completions
! Making improvements such as " Improving protocols per evidence based research " Creating checklists " Moving similar drugs to different storage locations in drawers
http://www.qualityindicatorys.ahrq.gov/
Just Culture
• An approach to medical error reporting that emphasizes learning and accountability over blame and punishment
• Basic knowledge • Everyone makes mistakes • Choice to follow the rules • Mistakes highlight opportunity
• Responsibility • Leaders set safety rules and make it possible to follow • Employees must follow safety rules and report safety events
http://psnet.ahrq.gov/ http://justculture.org/
Just Culture Punishing people for making mistakes generates fear of retaliation.
When employees are afraid to report errors and do not report, managers no longer learn about safety issues that need to be fixed before they happen.
Teaches managers/supervisors to evaluate what led to each event 1. Understand why the mistake occurred 2. Identify opportunities for improvement 3. Work with the employee
http://psnet.ahrq.gov/
Question 2:
• Describe the most important elements of a Just Culture approach to mistakes.
The three behaviors that fuel errors • Human error —accidentally doing something
unintended due to forgetfulness or a mistake • At-risk behavior —taking risks and not following
rules due to confidence an error will not result • Reckless behavior —taking risks known to be wrong
due to disregard and unconcern for potential harm
http://psnet.ahrq.gov/ http://www.ismp.org/ http://justculture.org/
Human Error: Unintentional; slip, lapse or mistake
Contributing factors: • Fatigue, lack of sleep, illness • Mental distractions, fear, worry, stress • Environmental distractions, noise, disruptions, clutter,
lighting • Too many hand-offs increasing the risk of
miscommunications
Managing Human Error
• Console employee • Empathize and listen • Recognize that we are all human and anyone could
have made the same mistake
Cause Human Error
Action Console
http://justculture.org/
At-risk Behavior: Taking risks; “Drift”
Contributing Factors: • Time pressures, sense of urgency • Multi-tasking • Drift away from standard processes and
redundancies because no negative consequences • Overconfident and take short-cuts • Watch others not following the rules with no bad
outcome
http://justculture.org/
Managing At-risk Behavior
• Coach the employees • Remind of risks • Coach whether or not there is any harm • Often practiced by more than one employee • Explain consequences for repeated behavior
Cause At-risk
Behavior
Action Coach
http://justculture.org/
Reckless behavior: Conscious disregard of rules
• Rare • Employee deliberately marginalizes patient
safety • Repeated at-risk behavior • Requires disciplinary action whether or not it
results in any harm
Cause Reckless Behavior
Action Disciplinary
Action
http://justculture.org/
Building a Culture of Safety
1. When employees trust that they can report a mistake without fear of punishment, and that their reports will be investigated and result in system improvements, they begin to trust more and report more of the safety conditions they see
2. As hospital leaders act on more safety reports, hospital systems improve and serious harm is avoided
3. In order for employees to trust their leaders, the hospital must have a fair and consistent way of managing errors
Question 3:
• What are barriers to reporting patient safety events?
Patient Safety in 2017-2018
Creating a Safety Culture
10.81 9.09
0
5
10
15
20
2016 2017 Rat
e pe
r 10,
000
Pat
ient
Vi
sits
Serious Safety Events (Harm F+) Harm
3.74
16.64
25.20
0 5
10 15 20 25 30
2015 2016 2017 Rat
e P
er 1
000
Pt V
isits
Overall Patient Safety Reporting Rate Per 1000 Patient Visits
Reporting
What we are learning?
0 2 4 6 8 10
Express Report Patient Actions
Skin/Eye/Wound Integrity Infections
Equipment/Supplies Lines, Drains, Airways - LDAs
Other Surgical/Invasive Procedure
Pharmacy Variances Laboratory Variances
Medication Procedure Variances
Event Rate Per 1000 Patient Visits 2017
943 PSRs
Medication Variances 0 10 20 30 40 50 60 70
Improper Dose
Wrong drug/IV fluid
Missed/omitted dose
Wrong time
Other
Wrong patient
Wrong administration route
Medication Obtained, Not Used
Labeling/Documentation error
Order Variance
No Harm Moderate Harm Harm
Improvements from PSRs
• Early Sepsis Recognition and Treatment
• Standardized medication order writing
• Implemented a checklist for Anesthesia equipment maintenance
• Improved surgical checklist
Improved Surgical Checklist
Services Impacted by 26 Improvements
Anesthesiology
ECC Gville
ICU
Imaging
Lab: Aquatic Pathology
Lab: Central Receiving
Lab: Clinical Microbiology
LAH
Large Animal Surgery
Medical Oncology
Pharmacy
Progressive Care Ward
SAH Surgery Ortho
Small Animal Internal Medicine
Zoo and Wildlife Medicine