The Epidemiology of Patient Safety and Medical Error

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The Epidemiology of Patient Safety and Medical
Error

• WVU Department of Family Medicine
• RCB HSC-Eastern Division
• Konrad C. Nau, MD

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(No Transcript)
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Man's heart stops after Bettis fumble
Pittsburgh Tribune
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Man goes into cardiac arrest at Cupka's bar, in
the South Side
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Man's heart stops after Bettis fumble
Pittsburgh Tribune
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Man's heart stops after Bettis fumble
Pittsburgh Tribune
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I made a mistake. Its my job to protect the
ball Jerome Bettis
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Why all this fuss about Patient Safety ?
                                                                                                               
               
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Prevalence

• Average of 1.7 mistakes per patient per day in
  ICU (out of 200 patient-care activities)
• 1 failure rate is too high to be tolerated
• At 99.9, there would be two unsafe plane
  landings at OHare airport each day, U.S.
  post-office would lose 16,000 pieces of mail, and
  32,000 bank checks would be deducted from wrong
  accounts every hour
• From Lucien Leape

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Aviation Model Error Happens
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Aviation Model Error Happens

• 1903 First Powered Flight
• 1908 First Pilot dies
• 1910 First mid-air collision
• 1918 31 of first 40 US Air Mail pilots die in
  crashes
• 1994 4 crashes/10,000,000 takeoffs

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Patient Safety

• The avoidance, prevention and amelioration of
  adverse outcomes or injuries stemming from the
  processes of health care.
• These events include "errors," "deviations," and
  "accidents."
• Safety emerges from the interaction of the
  components of the system it does not reside in a
  person, device or department.
• (Cooper, et al)

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Patient Safety

• Freedom from accidental injury
• establishment of operational systems and
  processes that
• minimize the likelihood of errors
• maximize the likelihood of intercepting them when
  they occur.
• (Kohn)

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Patient Safety

• actions undertaken by
• individuals
• organizations
• to protect health care recipients from being
  harmed by the effects of health care services.
• (Spath)

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Patient Safety Vocabulary

• Adverse Event
• Injury the results from medical care
• Preventable Adverse Event
• Error, could/should not have happened
• Non-Preventable Adverse Event
• Could not have been predicted or foreseen
• Potential Adverse Event
• Near miss or close call
• No harm doneerror intercepted

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Patient Safety Vocabulary

• Error
• the failure of a planned action to be completed
  as intended
• the use of a wrong plan to achieve an aim.

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Medical Error
Medical Errors
Any error in the health care delivery process
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Adverse Event
AE
Injury that results from medical care, not a
part of the natural disease process
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Adverse Events
Non-preventable Adverse Events
Medical Errors
AE
Preventable Adverse Events
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Near Miss
Near Miss- Potential Medical Error Intercepted
error
Medical Errors
Near Miss
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Medical Errors Adverse Events
Non-preventable
Medical Errors
AE
Near Miss
Preventable AE
Serious Medical Errors
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A Generic Model of Safety
Defenses can be hardware (e.g., monitors), people
(e.g., nurses) or administrative (e.g.,
acceptable protocols)
(From Managing the Risks of Organizational
Accidents, Reason, 1997)
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A Near Miss
Usually several defenses must fail to cause an
accident Just one remaining intact is enough to
prevent a near-miss becoming an accident
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A Harmful Event
What is the cause? The hazard? Failure of which
defense? This is the problem with assigning
single causesBlame/cause often is assigned to
the last barrier usually a person to fail!!
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Observed Path to Schedule and Complete a Doctors
Appointment
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Quality and Error
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UHA

• STATEMENT OF VALUES
• We will provide high-quality service and
  responsiveness to our patients and to each other
  that exceed expectations

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To Err is Human

• Process
• People

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To Err is Human

• Process 85
• People..15

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Errors are Treasures

• Every process is perfectly designed to achieve
  exactly the results it gets.
• As long as we keep on doing what we keep on
  doing, well keep on getting what weve got .

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The Swiss Cheese Model of Safety
Layers of Protection
Some holes due to active failures
Hazards
Other holes due to latent conditions
Adverse Event
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When all the holes lined up
Elevated PT INR
Lab tech
Result to office nurse
Physician interprets
Patient Falls Cerebral Hemorrhage
Patient contacted
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Errors

• Most organizational errors are made by
  well-intentioned human beingsmost highly
  educated, well trained, well intentioned human
  beingswho become accustomed to small glitches,
  routine foul-ups, and a culture that suppresses
  doing much about them in the name of an
  overriding goal.
• James Reason Internal Bleeding

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Latent Errors

• Latent errors process or system failures
• Pose the greatest threat to safety in a complex
  system because
• Lead to operator errors.
• They are failures built into the system and
  present long before the active error.
• Latent errors are difficult for the people
  working in the system to see since they may be
  hidden in computers or layers of management
• people become accustomed to working around the
  problem

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Six Changes That Save Hospital Patient Lives

• Deployment of Rapid Response Teamsat the first
  sign of patient decline
• Delivery of Reliable, Evidence-Based Care for
  Acute Myocardial Infarctionto prevent deaths
  from heart attack
• Prevention of Adverse Drug Events (ADEs)by
  implementing medication reconciliation
• Prevention of Central Line Infectionsby
  implementing a series of interdependent,
  scientifically grounded steps called the Central
  Line Bundle
• Prevention of Surgical Site Infectionsby
  reliably delivering the correct perioperative
  antibiotics at the proper time
• Prevention of Ventilator-Associated Pneumoniaby
  implementing a series of interdependent,
  scientifically grounded steps called the
  Ventilator Bundle

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Ambulatory Care is different

• Care is brief and episodic from the providers
  point of view
• Patients and clinicians have many degrees of
  freedom
• Feedback loops are long
• Adverse Events are often not directly seen or
  even reported

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Learning from Different Lenses Reports of
Medical Errors in Primary Care by Clinicians,
Staff and Patients
Robert Phillips John Hickner Deborah
Graham Susan Dovey Nancy Elder A Project of
the AAFP National Research Network Presented at
the 33rd NAPCRG Annual Meeting October 15-18,
2005 Quebec City, Quebec, Canada
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Context

• Primary Care
• ½ a billion office visits annually
• the medical home for most Americans
• Malpractice claims burden of serious harms and
  death from medical errors is substantial
• Most studies of errors reported by physicians
  important but limited lens

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Setting

• 10 family physician offices
• 5 private practices
• 5 residency clinics
• American Academy of Family Physician (AAFP)
  National Research Network
• mix of rural, urban, and suburban, private and
  community practices

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Asked to Report

• That should not have happened and that you dont
  want to happen again
• Small or large, administrative or clinical
• Could be events or processes that didnt happen
  but should have happened

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Results

• 401 physicians and staff signed a consent form
  and/or participated in site training (86 of
  eligible)
• Clinic physicians, NPs/PAs, residents, and staff
  reported 726 events, 717 with errors
• Staff 384 (53)
• physicians 278 (38)
• residents 46 (6)
• NPs and PAs 18 (3)
• 935 total errors

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Top Ten Errors (AAFP NRN)
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Error Consequences (AAFP NRN)
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Error Consequences (AAFP NRN)
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Patient reports (AAFP NRN)

• 6 reports of extended waiting
• 2 reports of mistaken identity
• 1 report each
• unnecessary blood-draw
• Prescriptions
• poor vaccination documentation
• unnecessary emergency room visits (unable to
  reach PCP)
• inability to get laboratory tests due to lack of
  insurance
• inappropriate comments by clinicians
• clinician-induced fear (patient left without
  treatment)
• credit card theft

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Clinician and Staff reports (AAFP NRN)

• 96 were process errors
• Clinicians were significantly more likely to
  report
• errors related to medications, laboratory
  investigations, and diagnostic imaging
• Staff were significantly more likely to report
• communication with patients and appointments.

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Multiple errors

• Multiple errors
• 4 reports contained four errors
• 33 reports contained three errors
• 183 cases two errors
• 93 cascades
• Chart completeness and availability medications
  appointments laboratory patient flow and
  filing systems.

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Consequences harms

• 706 reports had consequences or harms
• No patient died
• 3 patients required urgent care, were admitted to
  a hospital, or had to visit the emergency room
• 4 patients suffered pain or injury
• 10 patients health condition worsened
• Most placed the patient at heightened risk of
  harm (49), or made the patients, their families
  or their health clinicians upset (33).

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Seriousness

• Complex patients more likely very/extremely
  serious harm (31 vs. 20, p0.013)
• No difference in risk for patients with chronic
  conditions (29 vs. 21, p0.086)
• No differences for patients familiar vs.
  unfamiliar

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AAFP NRN Discussion

• Chaotic busy days, healthcare team communication
  failures, and breakdowns in protocols or
  guidelines often leave patients vulnerable
• Complex patients should raise concern of
  serious harms
• Reporters have difficulty divorcing systematic
  errors from blame

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AAFP NRN Discussion

• Multiple errors and error-cascades are common
• Patients either dont see errors often, wont
  report them understanding errors from their
  perspective will require another approach

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The Improving Medication Prescribing (IMP) Study

• Patient survey of primary care practices
  associated with a Boston teaching hospital
• Gandhi,TK. NEJM April 2004

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Adverse Drug Events reported in 25 of ambulatory
patients (IMP)
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Ameliorable Adverse Drug Events (IMP)
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IMP Prescription Review

• 1879 prescriptions reviewed
• Medication errors 143 8
• Potential ADE 62 3
• Life threatening 1 2
• Serious 15 24
• Significant 46 74

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Follow-up of Ambulatory Diagnostic Tests

• Tejal Ghandi, MD,MPH
• Eric Poon, MD,MPH
• Patient Safety
• Brigham and Womens Hospital

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Physician management of ambulatory test results

• Typical full-time primary care physician
• in ONE WEEK
• 820 lab results
• 40 diagnostic images
• 12 pathology reports
• Spends 72 minutes/day managing results
• 57 are NOT SATISFIED with the way they manage
  test results

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Physician management of ambulatory test results

• 75 of physicians did not notify patients of
  normal results
• 33 of physicians did not notify patients of
  abnormal results
• 33 of women with abnormal mamograms or PAP
  smears do not receive appropriate follow-up care

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Physician management of ambulatory test results

• Question How many times in the past 2 months
  have you reviewed test results you wish you had
  reviewed earlier ?

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Five Steps to Safer Health Care

• 1. Ask questions if you have doubts or concerns.
• 2. Keep and bring a list of ALL the medicines you
  take.
• 3. Get the results of any test or procedure.
• 4. Talk to your doctor about which hospital is
  best for your health needs..
• 5. Make sure you understand what will happen if
  you need surgery.

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SUMMARY

• Medical error and near-misses occur both in
  hospital and ambulatory settings
• Medical error is typically the result of process
  problems
• Patient Safety is the foundation for Quality
  Medical Care
• For a clinic to be dedicated to QUALITY , we must
  all be dedicated to Patient Safety