Introduction to Patient Safety

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Introduction to Patient Safety

• Nazanin Meshkat MD, FRCP, MHSc

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Lessons from Chernobyl

• Operators continued a planned test despite
  multiple indicators that things were going wrong
• System errors
• A shut down system that was too slow
• An over reliance on operators for system
  operation
• A lack of communication
• Poor planning

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Safety Critical Industries

• Nuclear plants
• Aviation
• Healthcare

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Objectives

• What is an unsafe act and error
• Understand why errors occur
• Human factors engineering
• To understand the role of teamwork and
  communication in patient safety

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Patient Safety

• World Health Organization definition
• "freedomfrom unnecessary harm or potential harm
  associated with healthcare

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To Err Is Human

• Institute of Medicine 1999
• 44,000 and 98,000 people die each year in US
  hospitals due to medical errors
• More than motor vehicle accident deaths in US

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Likely Under-Reported

• Errors are not always recognized when they occur
• Fear of punishment
• Reporting systems can be cumbersome.

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So what?

• Cost to
• Individual
• Family
• Health care providers
• Healthcare system

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• Centers for Medicare and Medicaid Services (CMS),
  more than one million patient safety incidents
  occurred to hospitalized Medicare patients in the
  US over the years 2002 to 2004, causing more than
  250,000 deaths and costing 9.3 billion

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Why do errors occur?
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Wards
Pharmacy
Lab
Limited Resources
Nurse Anesthetist
Drugs
Variable Pt Volumes
ER Doctor
Resident
Rapid Decisions
New Research, poor knowledge translation
Patient
High acuity
Many Distractions and interruptions
Nurse
Medical Student
Handoffs
Intern
Variability in practice
Radiology Department
Lab
Consultants
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SYSTEM
Information flow
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Transitions or handoffs

• Risky time
• Great deal of information to communicate
• Short amount of time
• Human factors - interruptions, tired
• Information is LOST, FORGOTTEN, MISCOMMUNICATED

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Dynamic non-event

• To make "nothing bad happen" requires a lot of
  good things to be done right.

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We all do unsafe things

• After a night shift, I got into my car to drive
  home, and while making a right turn, I rear-ended
  another car

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Unsafe Acts

• Errors
• Violations

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Errors

• Errors classified into two types of failures
• An action goes as intended but its the wrong one
  Mistake
• An action does not go as intended Error of
  Execution
• Slip - Action Based
• Lapse - Memory Based (a lapse in memory)

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Violations

• A deliberate deviation from an operating
  procedure, standard or rule
• Drift a slow, incremental move away from safe
  actions

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How do we make decisions

• Automatic cognition
• Active problem solving

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Automatic Cognition

• Concept of heuristics - cognitive shortcuts that
  allow for rapid, often unconscious decision
  making
• You get up in the morning, brush your teeth,
  shower

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Are these lines straight?
Optillusions.com
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Automatic Cognition

• Unfortunately, heuristics are also associated
  with cognitive biases that can be strong, but
  incorrect.
• Errors in Automatic Cognition are Caused by
  Errors of Execution (slips and lapses)

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Example of Heuristics

• DO----MINE - dopamine or dobutamine
• HY----ZINE - hydralazine or hydroxyzine

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Problem Solving

• Problem-solving is slow, conscious, sequential

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Problem Solving Errors

• Affected by habits of thinking
• Cognitive biases
• Memory bias
• Overconfidence
• Confirmation bias

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Both Automatic Cognition and Active Problem
Solving Affected by

• Internal Factors or endogenous causes
• Psychological states (anger, fear, boredom,
  anxiety)
• Physiological states (fatigue, illness)
• External Factors or exogenous causes
• Environmental factors (noise, heat, light), long
  work schedules, inadequate training,
  interruptions and distractions

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Both Automatic Cognition and Active Problem
Solving Affected by

• External Factors or exogenous causes
• Environmental factors (noise, heat, light)
• Long work schedules
• Inadequate training
• Interruptions and distractions

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Internal Factors
Peak Performance
Anxiety
Boredom
Stress Levels
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Internal Factors

• Impact performance and personality negatively
• Reduce decision-making ability
• Prolong response times
• Increase lapses in attention
• Affect short term memory
• Lessen ability to multitask
• Increase irritability, moodiness and depression
• Decrease ability to communicate

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Internal Factors

• After one night of missed sleep - performance can
  decrease by 25
• After 17 hours of being awake, the cognitive
  performance among test subjects equivalent to
  that of someone who was drunk
• Would you ever consider going to work drunk? Not
  likely but you probably go to work tired all the
  time.

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Latent Errors vs. Active Errors

• Latent errors are existing defects in the design
  and organization of processes and systems that
  can lead to failures and errors
• often unrecognized or just become accepted
  aspects of the work
• Lead to active errors, whose effects are felt
  immediately

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Latent Errors vs. Active Errors

• While the person on the front line - the doctor,
  nurse, or pharmacist - might be the proximal
  cause of the active error, the real root causes
  of the error is often present within the system
  for a long time, as accidents waiting to happen!

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Latent Errors vs. Active Errors

• The process of Normalization
• Acceptance of unacceptable processes

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How to Prevent Errors
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What does not work

• Blame and shame
• Countermeasures that have become the norm in
  medicine include
• Creating a sense of fear
• Disciplinary measures
• Threats of litigation
• Retraining (using outdated and ineffective
  training methods)
• Naming, blaming, and shaming.

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What works

• Instead of telling people to be more careful, you
  have to change systems
• Can redesign systems using human factors
  principles

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Human Factors Engineering

• Human factors is the study of the
  interrelationship between humans, the tools and
  equipment they use in the workplace, and the
  environment in which they work.
• How to design processes that make it easy for
  people to do things right
• and hard to do things wrong.

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How do you do that?

• Enhance mental and physiological states
• Reduce or mitigate fatigue, stress, dehydration,
  hunger, boredom, guilt, feeling undervalued, low
  moral, anxiety

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How do you do that?

• Enhance decision making AND execution
  throughEnvironment Design

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System Redesign

• Change Systems - Processes, procedures,
  communication, equipment, organizational culture

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System Redesign

• Change Systems - Processes, procedures,
  communication, equipment, organizational culture
• Simplify
• Standardize
• Use forcing functions and constraints
• Avoid reliance on memory
• Use redundancies
• Automate
• Promote effective team functioning

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Simplify

• My niece and nephew use their dads iPhone all
  the time!
• Because it is so simple to use!!

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Simplify

• Make tasks easy to do
• The simpler it is, the less chances an error will
  be made
• The more complex - users may work around it
  (e.g. skips steps)

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Simplify

• Make sure that an items purpose is easily
  understood by the user

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Standardize

• Eliminate
• Variation
• Confusion
• Complexity

• Enhance
• Uniformity
• Predictability
• Consistency

Examples - Protocols, Pre-Printed Medication
Order Forms, Clinical Care Pathways
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Use Forcing Functions and Constraints

• Constraint makes it difficult to complete a task
  (when indeed that task should not be completed)

• E.g Do not keep high dose Potassium Chloride in
  the medication cabinet to avoid accidental
  administration to a patient!

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Use Forcing Functions and Constraints

• Forcing Functions make it impossible to do a task
  incorrectly

• E.g When you are about to close up a document you
  have spent 6 hrs preparing without saving it, the
  software prompts you Do you want to save the
  document? before it lets you close the document

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Use Redundancies

• What?? You just said Simplify
• Redundancies, when carefully planned, can reduce
  errors in COMPLEX processes or those that can
  lead to significant harm
• Double check
• E.g. When giving blood products have two nurses
  read through patient info

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Avoid Reliance on Memory

• Human brain can reliably hold only between five
  and seven pieces of information at a time
• Use checklists
• E.g. For administration of certain medications or
  blood products
• E.g. During handover

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Automate

• But carefully
• Technology can be expensive, and just because you
  use technology, it will not lead to change
• The best technology in a broken system will fail
• Also has the potential to introduce yet another
  step, which could lead to more room for error,
  misinterpretation, increase workflow

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Automate

• In some countries there are Computer Prescriber
  Order Entry systems
• Studies found that they led to increased errors!

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Promote Effective Team Functioning
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Team Work

• What makes a successful Sports team makes a
  successful health care team!

• Work together
• No matter who you are in the team
• No matter how good you are, or your level of
  expertise
• Value expertise and input from others
• Communicate

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Team Work Work Together

• Engage all team members
• Encourage Feedback
• Respond constructively to suggestions

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Team work Value Each Other

• Psychological safety
• No blame, no undervaluing, no intimidation
• Respect and value every team members opinions,
  values, and emotions
• Every team member should be comfortable to speak
  up and communicate
• Every team member is treated with respect

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Team Work Communication

• Communication Tools
• Multidisciplinary rounds
• Briefings e.g. before our simulation cases
• Debriefing
• SBAR Situation, Background, Assessment,
  Recommendation
• Checklists
• Verbal Repeat backs - Closed loop conversations

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Error and Harm

• Not all Error leads to harm (thankfully!)
• But sometimes it does

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Swiss Cheese Model
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• Every error is an opportunity to improve the
  process

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Examples of what has worked
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WHO Surgical Safety Checklist

• A prospective study using the checklist showed
  the rate of death declined by almost 50 percent
  and the complication rate decreased by almost 40
  percent.

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Protocols

• Patient identifiers - and checking them during
  medication or blood administration
• Protocols to decrease surgical site infections
• Specimen labeling and handling
• Disinfection and sterilization
• Hand washing and sanitation

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Other..

• Medication bar coding to prevent medication
  errors
• Medical Emergency Teams (Rapid Response Teams)
• 65 reduction in cardiac arrests and a 24
  reduction in overall patient mortality
• Executive WalkRounds
• Effective Care Plans
• Delineate Responsibilities
• Delineate Timelines

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• A patient is having an acute heart attack when he
  arrives in the emergency department. Very
  rapidly, the team initiates care - giving
  medication to reduce the patients pain, giving
  medications to limit heart damage, and activating
  the cardiac catheterization lab team to quickly
  perform an angioplasty. As a result, the patient
  does quite well and leaves the hospital three
  days later with normal heart function.

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Tie into quality improvement

• Implement changes/recommendations using quality
  improvement projects
• Prevent an error before it happens

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First, do no harm