MEDICAL ERRORS

1
MEDICAL ERRORS
"We will either find a way, or make one". Hannibal

• Prof. dr. Janko KERSNIK, dr. med.
• Department of family medicine, University
  Ljubljana Maribor, Slovenia

2
OBJECTIVES

• TO GET FAMILLIAR WITH MEDICAL ERRORS CONCEPT
• TO COLLECT INFORMATION ON MISTAKES
• TO LEARN FROM MISTAKES

3
WHY MEDICAL ERRORS?

• NUMBERS There is a great number of adverse
  events that produce harm.
• CAUSATION Some adverse events are consequences
  of medical errors.
• AVOIDABILITY Many errors are preventable.
• CONTRIBUTION The errors of many individuals
  (active errors) converge and interact with
  system weaknesses (latent conditions),
  increasing the likelihood that individual errors
  will do harm Chassin MR, Becher EC, 2002.

4
ORGANISATIONAL MODEL

• The accidents occur irrespective of the skill of
  the designers and operators, hence they are
  "normal" and are difficult to prevent.
• As systems get more complex, the system becomes
  opaque to its users and therefore people forget
  to be afraid of potential adverse occurrences
  Mohr JJ, Batalden PB, 2002.

5
ORGANISATIONAL MODEL

• Human error is seen more as a consequence than a
  cause, and there is the need for proactive
  measures of "safety and health" with constant
  reform of the systems processes Mohr JJ,
  Batalden PB, 2002.
• Industries that have reduced serious errors to
  extremely low levels have done so by improving
  the performance characteristics of the systems in
  which the humans work Chassin MR, Becher EC,
  2002.

6
ADULT LEARNING CYCLE
7
ERROR LEARNING CYCLE
8
IMPACT OF ADVERSE EVENTS/COMPLAINTS

• lower quality of care
• harm to patients
• suits
• complaints
• financial loses
• personal dissatisfaction

9
RECOGNISING MISTAKES

• Effective reduction of medical/health care errors
  and other factors that contribute to unintended
  adverse patient outcomes in a health care
  organization requires an environment in which
  patients, their families, and organization staff
  and leaders can identify and manage actual and
  potential risks to patient safety JCAHO, 2002.

10
The solutions are within your group
Remember Each member can contribute to safety!
11
The leaders of the organization are responsible
for

• fostering such an environment through their
  personal example and by establishing mechanisms
  that support effective responses to actual
  occurrences
• ongoing proactive reduction in medical/health
  care errors
• integration of patient safety priorities into the
  new design and redesign of all relevant
  organization processes, functions, and services
  JCAHO, 2002.

12
The system...

• takes into account the concerns of the frontline
  personnel and is aimed at being a tool for
  learning and not accountability.
• must have as its primary focus the dissemination
  of positive actions that reduce or eliminate
  vulnerabilities that have been identified, not a
  counting exercise of the number of reports
  Bagian JP et al., 2001.

13
This environment encourages

• recognition and acknowledgment of risks to
  patient safety and medical/health care errors
• the initiation of actions to reduce these risks
• the internal reporting of what has been found and
  the actions taken
• a focus on processes and systems

14
This environment encourages

• a minimization of individual blame or retribution
  for a medical/health care error
• organizational learning about medical/health care
  errors and supports the sharing of that knowledge
  to effect behavioural changes in itself and other
  health care organizations to improve patient
  safety JCAHO, 2002.

15
TRACKING ADVERSE EVENTS

• To reduce or prevent the occurrence of adverse
  events in primary care, better systems for
  recognising and tracking them and for assessing
  their causes are needed Fischer G, et al.,
  1997.

"Events of importance are the result of trivial
causes. Julius Caesar
16
TRACKING MISTAKES

• reporting on incidents
• internal audit
• complaints
• surveys
• unexpected deaths
• coroner reports
• literature search
• media reports, etc.

"If error is corrected whenever it is recognised
as such, the path of error is the path of truth".
Hans Reichenbach
17
REPORTING ON INCIDENTS

• medical record review,
• clinical incident reporting,
• occurrence screening,
• significant event auditing,
• processes for dealing with complaints,
• the national confidential enquiries into various
  areas of clinical care (in the UK, introduced in
  Slovenia), etc. Kieran W, 2000.

18
ANALYSING INCIDENTS

• To determine latent and active errors and ranked
  in order of risk severity. Wolff AM, Bourke J,
  2000.
• The effect on the patient is rated, in terms of
  their severity and temporal persistence, and
  their effect on the organisation and the costs of
  health care Kieran W, 2000.
• An assessment of the existence of negligence is
  made.

19
ANALYSING INCIDENTS

• The cause of the event is explored.
• The distinction between healthcare system and
  underlying disease process or other causes, and
  to attribute events to particular parts of the
  healthcare organisation is made.
• The avoidability of events or the acceptability
  of the standard of care provided may also be
  rated.

20
PLANNING CHANGE

• We must overcome any temptation to be less than
  fully candid Chassin MR, Becher EC, 2002.
• The communication between and among health care
  providers and patients that work toward building
  better relationship ties have demonstrated the
  potential for greater patient safety Bender NL,
  2000.

21
SAFE ORGANISATIONS

• Organisational elements that appear to promote
  high reliability are
• selection and training of personnel,
• redundancy of functions (equipment, procedures),
• reliance on collegiality and negotiation within a
  tight formal command structure,
• a culture emphasising cooperation and commitment
  to high standards West E, 2000.

22
IMPLEMENTING CHANGE

• Action is then planned and implemented to prevent
  the event from recurring.
• Effective actions include
• simplifying systems,
• standardising procedures,
• introducing constraints,
• using reminders and checklists,
• providing timely information,
• and small-group interactive education Wolff AM,
  Bourke J, 2000.

23
HUMAN CONTIRBUTION

• The fleeting psychological precursors of
  fallibilityfor example, inattention or
  forgettingare the last and the least manageable
  aspects of the error producing sequence Reason
  JT, Carthey J, de Leval MR, 2001.
• Factors that increase the likelihood of
  individuals making errors can never be completely
  eliminated. Human performance can be improved but
  not perfected Chassin MR, Becher EC, 2002.

24
SYSTEM CONTIRBUTION

• The compartmentalisation of work increases the
  likelihood of adverse events by introducing the
  need for communication and monitoring, to the
  problem of "many hands" and the diffusion of
  responsibility that can occur in organisations.
• It can often be extremely difficult to determine
  an individual's contribution to patient care
  West E, 2000.

25
WHAT DID WE LEARN?

• Avoid the attractions of the "person model by
  limiting the remedial efforts by attempting to
  change the behaviour of an individual by blaming,
  shaming, naming, and retraining the frontline
  personal.
• Errors and non-compliances mark the starting
  point of an investigation, not its conclusion
  Reason JT, Carthey J, de Leval MR, 2001.

26
HUMAN FACTORS

• doctor patient communication skills
• communication between providers
• coping with mistakes
• cooperation with other providers
• documentation of the interventions
• incident reporting
• "The cautious rarely err." Confucius

27
HUMAN FACTORS - STRESS

• Loss of sleep rather than long hours of work
  cause decrements in mood and performance,
• The quality of sleep is inferior in those on
  call, expecting to be woken,
• Stressors are counteracted by positive aspects of
  work, such as support from colleagues and
  seniors.
• We also know that membership of a well
  functioning team reduces stress levels and
  increases performance Firth-Cozens J, Moss F,
  1998.

28
ORGANISATIONAL FACTORS

• non blaming environment
• system for tracking (reporting) adverse events
  and mishaps, analysing root causes and corrective
  actions
• supporting individuals and groups in reporting on
  critical events West E, 2000

Mistakes of all kinds are a normal part of
work. West
29
ORGANISATIONAL FACTORS

• system simplicity,
• standardisation and formalisation
• diminished status differences,
• overcoming role boundaries
• job design, individuals career development,
• diminished environmental pressures West E, 2000

30
ORGANISATIONAL FACTORS

• greater standardisation of common activities and
  customisation of care to individual patients,
• greater use and analysis of information to
  support daily work,
• consistent measured improvement in performance,
• extensive cooperation and teamwork across
  disciplines and specialities within the
  microsystem, and
• an opportunity for spread of best practices
  across microsystems within their larger
  organisations Mohr JJ, Batalden PB, 2002

31
ORGNISATIONAL FACTORS

• To design and implement a system that takes into
  account the concerns of the frontline personnel
  and is aimed at being a tool for learning and not
  accountability.
• Their primary focus is the dissemination of
  positive actions that reduce or eliminate
  vulnerabilities that have been identified, not a
  counting exercise of the number of reports.
  Bagian JP et al., 2001

32
SOME PRINCIPLES

• One of the basic principles of error management
  is that the best people can make the worst
  mistakes.
• Despite all the intuitive evidence to the
  contrary, it is far easier to fix situations than
  to change people, and this is the only way to
  achieve institutional resilience in health care.
• Errors are almost always systemic consequences
  rather than isolated causes Reason JT, Carthey
  J, de Leval MR, 2001.

33
CONCLUSION

• Medical errors as causes of adverse events are
  inevitable part of our daily practice.
• We can learn from disasters that human
  contribution to unintended adverse events occurs
  only in the presence of system failures.
• We can and have to teach our students and
  trainees about safe working conditions and risk
  management.

34

• "An expert is a man
• who has made all the mistakes
• which can be made.
• Niels Bohr

"An expert is a man who has learnt from all the
mistakes which can be made. after Niels Bohr