Reducing Medical Errors, Promoting Patient Safety

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• Reducing Medical Errors, Promoting Patient Safety

Every Patients RightEveryones Responsibility
Primum non nocere - Hippocrates
Sharon Levine, MD Associate Executive
Director Kaiser Permanente October 20-21,
2008 Beijing, China
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• Medicine used to be simple, effective and
  relatively safe - now it is complex, effective,
  and potentially dangerous
• Sir Cyril Chantle
• 44,000-98,000 patients die each year in
  hospitals from medical error IOM report May
  be as high as 195,000 deaths per year Health
  Grades 2004
• Our Challenge
• Preventing harm to patients from the care
  intended to help them

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Accidental Deaths in the U.S.
(National Safety Council, Harvard School of
Public Health, 1999)
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How Do We Compare?
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Top Patient Concerns About Hospital
Stays

• Negative interaction of medications 58
• Getting the wrong medications 61
• Cost of treatment 58
• Procedural complications 56
• Having enough drug information 53
• Getting an infection during stay 50
• Suffering from pain 49

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Basis 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

Requires more than paying attention and trying
hard
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Basis of Error - Complexity

• 80 medical error is system derived
• 95 mistakes the good guys
• Identify and address the human factors
• Fix the system
• Understand the difference

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Culture of Safety

• Awareness, understanding, and ownership of
  safety by all
• Constant vigilance to prevent error
• Learning from errors that do occur, and minimize
  chance of recurrence
• Teamwork, not hierarchy or autonomy
• Communication and hand-offs
• Non-punitive environment - encourage reporting of
  errors and near-misses
• Systems to mitigate human factors
• Memory capacity
• Mental processing
• Stressors fatigue, emergencies

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Behavior
Biggest barrier to preventing errors punishing
people for making mistakes

• Human error--inadvertently doing other than what
  should have been done slip, lapse, mistake -
  console
• At risk behavior - behavior where risk is not
  recognized, or is mistakenly believed to be
  justified - coach
• Reckless behavior - conscious disregard of a
  substantial and unjustifiable risk remedial,
  then disciplinary action
• David Marx

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Culture of Systems

• From patient-specific to systems view
• Indentifying patterns of error
• Standardization where appropriate processes,
  procedures, checklists, standardized orders
• Care team accountability for error identification
  and elimination
• Expert team vs. team of experts communication,
  simulation, attention to hand-offs

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Drivers of Hospital Mortality and Morbidity
Goals Drivers Focus Areas
Initiatives
Infection Reduction
No Needless Harm/Deaths
Falls and pressure ulcers
High Alert Medication Program
Highly Reliable Surgical Teams
Reduce Hospital Mortality and Morbidity
Disease-specific care AMI, HF, PN, SCIP, CVA,
glucose control
Evidence- Based Care
Early goal-directed therapy
Anticipating end of life Palliative Care,
Advance Directives
Appropriate Care Setting
Access to alternative care settings SNF, HH,
rehab
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High Alert Medication Program

• High Alert Drug List
• Standardize policies and procedures
• Education, training and retraining
• No-interruption zone, -wear
• Peer observations
• Measure, monitor, feedback
• Peer group share learnings
• Leadership focus, oversight

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Zone
MedRite
The Zone is an area marked out in
front of the PYXIS to signify a no interruption
area. Use of tape is a common zone indicator in
hospitals such as in the OR and Pharmacy
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No Interruption Wear (NIW) is the tool that helps
minimize interruptions during medication
administration Worn ONLY during the Medication
administration process Allows the nurse to be
interrupted at appropriate times
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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
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System Redesign for SafetyHighly Reliable
Surgical Teams
From Art to Science Translating Evidence
into Benefit
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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
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Early Evidence of Benefit

• 40 reduction in surgical complications since
  2001
• From one surgery-related injury per 48 days (2003
  to 2007) to one in 280 days (and counting) 2008
• Significant and sustained improvement in abx
  use/time/duration (97) normothermia (95) beta
  blocker use (97)

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Early Evidence Surgical Care Improvement Program
(SCIP)
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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
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SCIP Composite of Antibiotic Choice, Timing and
Duration
60
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40
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