Prevention of Medical Errors

2012

Mary Mckay DNP, ARNPAssistant Professor

University of Miami School of Nursing and Health Studies

Scope of the ProblemThe Institute of Medicine study- “ To Err is

Human”-1999 found

• 44,000 - 98,000 Americans die in hospitals each year from medical errors

• Medication related errors result in

7,000 deaths each year.

• $37.6 billion and 50 billion dollars in associated costs

Over 10 years later Is Health Care Safer Today?

It is very Difficult to Assess due to:

• Lack of universal reporting system

• Under reporting

• Lack of consensus regarding terminology/definitions of what constitutes an error

Why are errors under reported?

1. Historically a punitive approach has been

taken when an error occurs leading to fear of :

• Loss of reputation

• Loss of job

• Disciplinary action by professional board

• Malpractice

Why are errors under reported?

2. Difficult to use reporting systems

3. Time constraints

4. Sweep it under the rug mentality- as long as no one was hurt no need to talk about it

Increasing Awareness For Patient Safety

• Several national and international initiatives involving patient safety promotion will be introduced .

The Use of Simulation and Safety

What are the benefits of learning through simulation?• Allows for learners to perform in an environment that is

as close as possible to a real patient scenario• Learners acquire and practice skills in a safe

environment• Mistakes made while training will not harm a real patient

An opportunity to improve patient safety thru teamworkand critical event training.”( American Society ofAnesthesiologists, 2008). As a student at UMSONHS you will have the opportunity to use simulation.

Institute for Healthcare Improvement is currently addressing:

• Adverse Drug Events (ADE)• Catheter-Associated Urinary Tract Infections (CAUTI)• Central Line Associated Blood Stream Infections (CLABSI)• Injuries from Falls and Immobility• Obstetrical Adverse Events• Pressure Ulcers• Surgical Site Infections• Venous Thromboembolism (VTE)• Ventilator-Associated Pneumonia (VAP)• Other Hospital-Acquired Conditions

Posted on: April 12, 2011 http://www.ihi.org/IHI/Programs/ImprovementMap/Institute for Health Care Improvement @ IHI.org

The World Health Organization (WHO) Initiatives Include

• Clean Care is Safer Care

• Safe Surgery Saves Lives

• WHO Safety Check list

http://www.who.int/patientsafety/about/en/index.html

Joint Commission

• The Joint Commission is an accrediting agency that supports safe quality patient care. They have developed a sentinel event policy and patient safety goals that will be discussed in more detail.

Review of Common Terminology

• Medical Error

• Adverse Event

• Near Miss

• Sentinel Event

What is a Medical Error ?

According to the Institute of

Medicine(1999) a medical error is

defined as “ the failure of a planned

action to be completed as intended or the use of a wrong plan to achieve an aim”.

What is anADVERSE EVENT ?

• An event in which a negative outcome occurred as a result of medical intervention rather than from the underlying medical condition.

What is a 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.

• Warning sign• Increased reporting needed

Case Study #1• A 55 year old man presented to an ER with fever.

Following an assessment the MD ordered an IV antibiotic and an antifungal IV drug- Diflucan . The nurse requested the Diflucan from the pharmacy. A 50ml bottle of Diprivan (sedative hypnotic agent) was sent to the ER erroneously labeled as

“ Diflucan 100mg/ml”. The nurse noted the bottle contained an opaque solution rather than the usual clear plastic bag of Diflucan she was familiar with.

While she was initiating a phone call to the pharmacy for clarification, a MD demanded her immediate assistance.

Reference: http://www.ahrq.gov

Case StudyShe returned to the patient and hung the

Diprivan via the patient’s central line. The IV

pump alarmed “air in line” almost immediately.

While removing the air from the line the nurse

was once again alerted to the discrepancy she

had noted earlier. She removed the Diprivan

and contacted the pharmacy. Fortunately, the

patient had not received any of the Diprivan yet.

Reference: http://www.ahrq.gov

What Happened ?

Near Miss

• This is an example of a “Near Miss”

• One of the contributing factors in this case was the fact the nurse was interrupted during the event. Interruptions and distractions increase errors.

What is a Sentinel Event?• The Joint Commission developed a Sentinel

Event Policy and database in 1996 of all reported events.

• Used to analyze events to provide information to healthcare organizations to deter future occurrences.

Joint Commission http://www.jointcommission.org/

What is a Sentinel Event?• A sentinel event is defined as an unexpected

occurrence involving death or serious physical, or psychological injury, or risk thereof

• Sends a signal or warning that requires immediate attention

• Is not synonymous with “medical error”

Agency for Healthcare Research and Quality

http://www.ahrq.gov

What is a Root Cause and Analysis ?

• A process for identifying the causative factors involved in the occurrence of a sentinel event

• A root cause is the most basic reason for the failure or inefficiency of a process

• Focuses primarily on systems/processes, not individuals

Joint Commission Identified Root Causes of Sentinel Events for All Categories

• Communication

• Orientation/Training

• Patient Assessment

• Availability of information

• Staffing levels

• Physical environment Issues

Joint Commission Identified Root Causes of Sentinel

Events• Events for All

Categories• Continuum of care• Competency/ Credentialing• Procedural compliance• Alarm systems• Organizational Culture

FAILURE MODES & EFFECT ANALYSIS

• Another method to prevent errors• Process applied prior to actual error• Examines a system/process for possible high risk

points of error• Possibly redesign the process to eliminate chance of

failure• Pilot test• Implement the process• Reevaluate the possible risk of errors• Institute precautions if needed

Why Do Errors in Health Care Occur ?

“Medical errors most often result from a

complex interplay of multiple factors. Only

rarely are they due to the carelessness or

misconduct of single individuals” L. Leape, MD.

WHY DO SYSTEMS FAIL?

• COMPLEXITY• VARIABILITY• INCONSISTENCY• TIME CONSTRAINT• HUMAN INTERVENTION• HIEARCHICAL CULTURE “ I’m in charge do as I say”• TIGHT COUPLING

Types of System Errors/Failures

• Active errors/failures involve personnel and parts of the health care system that are in direct contact with the patient.

• Their actions may result in errors that have a direct impact on patient safety

• Referred to as errors occurring at the sharp end. Reason, JT. (1990). Human Error. New York, NY:Cambridge University

Types of System Errors/Failures

• Latent errors/failures involve individuals such as managers, administrators and policy makers

• Their actions or decisions may lead to a negative impact on patient safety. Tend to be less obvious.

• Referred to as errors occurring at the blunt end

Reason, JT. (1990). Human Error. New York, NY:Cambridge University

Types of System Errors/Failures

Blunt End Sharp End Latent Active