Case Presentation

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Case Presentation

• 25 yo g2p1 at 41 weeks
• Induction scheduled and begun
• Long and slow, AROM finally
• That night, at home
• What went wrong?
• How can this be avoided in the future?

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Patient Safety and Human Factors Engineering

• LTC Gary W. Clark, MD MPH

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• Define Error
• Define Patient Safety

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To Err is Human

• Errors will always happen
• They may be irrelevant
• We need to design systems that mitigate errors
  before they harm patients
• It is not about blame

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Patient Safety

• Identification and control of hazards that could
  cause harm to patients
• Prevention of harm/injury to patients
• Providing a safe environment in which to practice
• Quality care must be safe care

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Semantics or Reality?

• Wrong leg is amputated
• Wrong medication is dispensed
• Diagnosis is too late to save a patient with
  meningitis
• You almost do an LP on the wrong pt
• Focus not on blame but on pt safety

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Adverse Events

• Unwanted incidents
• Therapeutic misadventures
• Iatrogenic injuries
• Adverse occurrences
• Result from commission and omission
• Does it really matter who did it?

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Who Cares?

• Medical errors may be common, but seldom do
  patients get harmed by them

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Causes of Death US 2000

• Heart disease 710,760
• COPD/Asthma 122,000
• Diabetes 69,301
• Alzheimers 49,558
• MVA 41,994
• Medical Error (00) 44,000-98,000
• Inpt only (04) 191,000

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Studies have shown

• IOM study based on these data
• ICU 1.7 events/pt/day
• IM rounds 50 of pts w/1-10 events
• FM 50 of patients with events

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96-98 Reliability in Hospitals

• 99.9 reliability is
• 1 hour of unsafe drinking water per month
• 2 unsafe landings at OHare per day
• 16,000 pieces of lost mail per day

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96-98 Reliability in Hospitals

• 22,000 checks deducted from wrong account per
  hour
• 20,000 incorrect prescriptions/year
• 500 incorrect operations each week
• Actual numbers for hospitals are 20-40x

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• So why do this many mistakes happen?

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It is Usually the System

• Personal approach
• Focus on a person
• Poster campaigns
• New procedures
• Discipline methods
• Threat of litigation
• Blame, shame
• Retrain

• System approach
• Focus on conditions and environments
• Build fault tolerance into the system
• Creating a better system

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Is MAMC a No-Fault System?

• How do we report mistakes?
• How is this information handled by the hospital?
• What venues do we use to discuss mistakes?

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Population Health

• Reduce disease
• Look for risk factors
• How do they contribute to disease?
• Reduce or eliminate risk factors
• Mitigate the effect on patients

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Patient Safety

• Reducing adverse events
• Look for hazards
• How do they contribute to adverse events?
• Find solutions to reduce/eliminate hazards
• Mitigate impact on patient safety

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Human Factors Engineering

• Designing systems, devices, tools to fit human
  capabilities and limitations
• Get info re hidden needs of end-user
• Unexpected interactions between the system and
  the end-user

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Human Factors Engineering

• Well studied in
• Aviation
• Nuclear power
• Space flight
• Software design
• Palm pilots
• Why?

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Radar Scope to Detect enemy ships
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Performance Graph
100
90
80
70
Performance
1
2
3
4
Time (hours)
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Performance Graph
100
90
80
70
Performance
1
2
3
4
Time (hours)
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How can we move the curve upwards?
100
90
80
70
Performance
1
2
3
4
Time (hours)
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It is Easy to Miss Stuff

• Look at the next slide
• Count the number of words in the paragraph that
  are repeated

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Exercise

• The last time we got together to camp in Nova
  Nova Scotia we we decided that it would be too
  cold to sleep in a tent. So, I called the motel
  motel that was located near Peggys Cove on on
  top of the hill. We should call each other and
  talk about these plans once and for all. If you
  cannot call me, the the best way to get in touch
  is by fax fax machine.

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Exercise

• The last time we got together to camp in Nova
  Nova Scotia we we decided that it would be too
  cold to sleep in a tent. So, I called the motel
  motel that was located near Peggys Cove on on
  top of the hill. We should call each other and
  talk about these plans once and for all. If you
  cannot call me, the the best way to get in touch
  is by fax fax machine.
• Answer is 3?

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Exercise

• The last time we got together to camp in Nova
  Nova Scotia we we decided that it would be too
  cold to sleep in a tent. So, I called the motel
  motel that was located near Peggys Cove on on
  top of the hill. We should call each other and
  talk about these plans once and for all. If you
  cannot call me, the the best way to get in touch
  is by fax fax machine.
• Or is the answer 6?or is it 14?

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Now, State the Color of the Text as Fast as You
Can
Yellow
Green
Red
Blue
Row 1
Green
Red
Blue
Yellow
Row 2
Red
Blue
Yellow
Green
Row 3
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Again, State the Color of the Text as Fast as
You Can
Red
Blue
Green
Yellow
Row 1
Yellow
Green
Red
Blue
Row 2
Blue
Yellow
Green
Red
Row 3
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Tell the nursing student to attach the oxygen
mask and tubing to the green spigot
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• What could you do to fix this problem?

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Weaker vs. Stronger Remedy
Better
Make sure to use the correct color Adaptor!?
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Sources Medical Mistake Left Newborn In
Coma KITV-TV HONOLULU - A medical mistake at
Tripler Army Medical Center has left a newborn
baby in a coma with severe brain damage. Sources
familiar with this case tell KITV 4 News that
Tripler officials apologized to the family of a
baby boy born there in January after he was
mistakenly given carbon dioxide right after
birth, instead of oxygen. The baby boy was born
Jan. 14 at Tripler Army Medical Center during a
scheduled cesarean section delivery, sources told
KITV 4 News. They said medical personnel
mistakenly gave him carbon dioxide immediately
after birth instead of oxygen. Sources said the
operating room may have been set up incorrectly.
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Medical Software Correlation
- Pharmacist uses 95 of time - Enter button to
enter data
- Pharmacist uses 5 of time - Spacebar to
enter data
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• Do we have any computer systems like this?

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HFE and Patient Safety

• We often have a pre-set focus during
  interpretation
• How much can a clinician attend to in an ICU
  room?
• Patient
• Monitor
• IV Pump

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• Ball passing video

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Normalization of Complexity

• Encouraged
• Mastery of the complex becomes the normal
  strategy
• No regard for reasonableness or necessity of
  complexity

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Baseline Drawer (Laundry hamper)Range
243-358 min, Avg307 min
Note the multiple orientations
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Code Cart Drawer Fifth Version Range 55-125
min, Avg108
Note the lack of labels for each spot
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Human Factors Engineering

• Your stories of
• Adverse events
• Close calls
• Human factor engineering issues
• Cryo Gun
• ACLS drugs
• Induction of 35 week gestation
• ACLS on stab wound victim

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Take Home Points

• Adverse events are common
• People are injured or die
• It is the system, not the person
• Human factors engineering helps
• Look for hazards and address them