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Reducing Medical Errors, Reducing Medical Errors, Promoting Patient SafetyPromoting Patient Safety
Sharon Levine, MDSharon Levine, MDAssociate Executive DirectorAssociate Executive DirectorKaiser PermanenteKaiser PermanenteOctober 20-21, 2008October 20-21, 2008Beijing, ChinaBeijing, China
Primum non nocerePrimum non nocere - Hippocrates - Hippocrates
Every Patient’s RightEvery Patient’s RightEveryone’s ResponsibilityEveryone’s Responsibility
“ “Medicine used to be simple, effective and Medicine used to be simple, effective and relatively safe - now it is complex, effective, relatively safe - now it is complex, effective, and potentially dangerous”and potentially dangerous”
Sir Cyril ChantleSir Cyril Chantle
“ “44,000-98,000 patients die each year in 44,000-98,000 patients die each year in hospitals from medical error” hospitals from medical error” IOM report IOM report May be as May be as high as 195,000 deaths per year high as 195,000 deaths per year Health Grades 2004Health Grades 2004
Our Challenge:Our Challenge: Preventing harm to patients from the care Preventing harm to patients from the care
intended to help themintended to help them
22
Accidental Deaths in the U.S.
120,000
43,649
14,9863,959 329
0
20,000
40,000
60,000
80,000
100,000
120,000
Medical ErrorDeaths
MVA Deaths Fall Deaths DrowningDeaths
Plane Deaths
(National Safety Council, Harvard School of Public Health, 1999)(National Safety Council, Harvard School of Public Health, 1999)
33
How Do We Compare?
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
To
tal
liv
es
lo
st
pe
r y
ea
r
REGULATEDDANGEROUS(>1/1000)
ULTRA-SAFE(<1/100K)
HealthCare
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
44
Top Patient Concerns AboutTop Patient Concerns About Hospital Stays Hospital Stays
Negative interaction of medicationsNegative interaction of medications 58%58%
Getting the wrong medicationsGetting the wrong medications 61%61%
Cost of treatmentCost of treatment 58%58%
Procedural complicationsProcedural complications 56%56%
Having enough drug informationHaving enough drug information 53%53%
Getting an infection during stayGetting an infection during stay 50%50%
Suffering from painSuffering from pain 49%49%
55
Basis Of Error– ComplexityBasis Of Error– Complexity
Powerful drugs Highly technical
equipment/products Rapid decisions; time
pressured Many care givers; multiple
“handoffs” Task-based versus Systems-
based
Limited resources Complex human factors High acuity illness / injuries Environment prone to
distraction Variable patient volume;
variable patient flow flow
Staff
Management System
Equipment/Technology
Environment
Patient
66Requires more than “paying attention” and “trying hard”Requires more than “paying attention” and “trying hard”
80% medical error 80% medical error is system derivedis system derived
95% mistakes— 95% mistakes— the good guysthe good guys
Identify and Identify and address the human address the human factorsfactors
Fix the systemFix the system Understand the Understand the
differencedifference
Basis of Error - ComplexityBasis of Error - Complexity
77
“Culture of Safety”
Awareness, understanding, and ownership of safety Awareness, understanding, and ownership of safety by all by all
Constant vigilance to prevent errorConstant vigilance to prevent error Learning from errors that do occur, and minimize Learning from errors that do occur, and minimize
chance of recurrencechance of recurrence Teamwork, not hierarchy or autonomyTeamwork, not hierarchy or autonomy Communication and hand-offsCommunication and hand-offs Non-punitive environment - encourage reporting of Non-punitive environment - encourage reporting of
errors and near-misseserrors and near-misses Systems to mitigate “human factors”Systems to mitigate “human factors”
Memory capacityMemory capacity Mental processingMental processing Stressors: fatigue, emergenciesStressors: fatigue, emergencies
88
Behavior
Human error--inadvertently doing other Human error--inadvertently doing other than what should have been done; slip, than what should have been done; slip, lapse, mistake - lapse, mistake - consoleconsole
At risk behavior - behavior where risk is At risk behavior - behavior where risk is not recognized, or is mistakenly believed not recognized, or is mistakenly believed to be justified - to be justified - coachcoach
Reckless behavior - conscious disregard Reckless behavior - conscious disregard of a substantial and unjustifiable risk – of a substantial and unjustifiable risk – remedial, then disciplinary actionremedial, then disciplinary action
David MarxDavid Marx
Biggest barrier to preventing errors – punishing Biggest barrier to preventing errors – punishing people for making mistakespeople for making mistakes
99
“Culture of Systems”
From patient-specific to systems viewFrom patient-specific to systems view Indentifying patterns of errorIndentifying patterns of error Standardization where appropriate: Standardization where appropriate:
processes, procedures, checklists, processes, procedures, checklists, standardized ordersstandardized orders
Care team accountability for error Care team accountability for error identification and eliminationidentification and elimination
Expert team vs. team of experts: Expert team vs. team of experts: communication, simulation, attention to communication, simulation, attention to hand-offshand-offs
1010
Reduce Hospital Mortality and Morbidity
Infection Reduction
Falls and pressure ulcers
Early goal-directed therapy
High Alert Medication Program
Highly Reliable Surgical Teams
Disease-specific care: AMI, HF, PN, SCIP, CVA, glucose control
Anticipating end of life: Palliative Care, Advance Directives
Access to alternative care settings: SNF, HH, rehab
Goals Drivers Focus Areas & Initiatives
Drivers of Hospital Mortality and Morbidity
Evidence- Based Care
Appropriate Care Setting
No Needless Harm/Deaths
1111
High Alert Medication Program
High Alert Drug ListHigh Alert Drug List Standardize: policies and proceduresStandardize: policies and procedures Education, training and retrainingEducation, training and retraining No-interruption zone, -wearNo-interruption zone, -wear Peer observationsPeer observations Measure, monitor, feedbackMeasure, monitor, feedback Peer group: share learningsPeer group: share learnings Leadership focus, oversightLeadership focus, oversight
1212
ZoneZoneMedRite
The Zone is an area marked out The Zone is an area marked out in front of the PYXIS to signify in front of the PYXIS to signify a “no interruption” area.a “no interruption” area.
Use of tape is a common zone Use of tape is a common zone indicator in hospitals such as in indicator in hospitals such as in the OR and Pharmacythe OR and Pharmacy
1313
No Interruption Wear (NIW) is No Interruption Wear (NIW) is the the tooltool that helps minimize that helps minimize interruptions during medication interruptions during medication administration administration
Worn ONLY during the Worn ONLY during the Medication administration Medication administration processprocess
Allows the nurse to be Allows the nurse to be “interrupted” at appropriate “interrupted” at appropriate timestimes
1414
Percentage change from 1st mean (13.23
Jan to June ’06) to 2nd mean (26.0) June to
April ’07: 97%
From April ’07: Days since last event:
445 and counting
1515
From “Art to Science” – From “Art to Science” – Translating Evidence into BenefitTranslating Evidence into Benefit
Clinical Research
Evidence Implementation Benefit
REDESIGNING PROCESSES
System Redesign for Safety:Highly Reliable Surgical Teams
1616
Clinical Research
Evidence Implementation Benefit
System Redesign for Safety
Check lists
Teamwork
Time-out
Standardized orders
Safety Summit
Safety team in every OR
Standardized orders
Checklist for every role
Observation/audit
Debrief
Simulation
Training
Report cards
1717
Early Evidence of Benefit
40% reduction in surgical complications 40% reduction in surgical complications since 2001since 2001
From one surgery-related injury per 48 days From one surgery-related injury per 48 days (2003 to 2007) to one in 280 days (and (2003 to 2007) to one in 280 days (and counting) 2008counting) 2008
Significant and sustained improvement: in Significant and sustained improvement: in abx use/time/duration (97%); normothermia abx use/time/duration (97%); normothermia (95%); beta blocker use (97%)(95%); beta blocker use (97%)
1818
Early Evidence: Surgical Care Early Evidence: Surgical Care Improvement Program (SCIP)Improvement Program (SCIP)
SCIP Composite of Antibiotic Choice, Timing and Duration
100%
90%
80%
70%
60%
50%
40%
Regional SCIP Performance
Quarter 1 2008
SCIP Abx Timing: 96%
SCIP Abx Choice: 98%
SCIP Abx Duration: 95%
Hair Removal: 99%
Normothermia: 92%
Beta Blocker: 97%
VTE composite: 94%
1919