Reducing medical error and increasing patient safety Richard Smith Editor, BMJ

What I want to talk about A story How common is error? Why does error happen? How should we think of error? How should we respond?

A story

How common is error?

Why does error happen?

How should we think of error?

How should we respond?

A story

How common is error? Harvard Medical Practice Study Reviewed medical charts of 30 121 patients admitted to 51 acute care hospitals in New York state in 1984 In 3.7% an adverse event led to prolonged admission or produced disability at the time of discharge 69% of injuries were caused by errors

Harvard Medical Practice Study

Reviewed medical charts of 30 121 patients admitted to 51 acute care hospitals in New York state in 1984

In 3.7% an adverse event led to prolonged admission or produced disability at the time of discharge

69% of injuries were caused by errors

How common is medical error? Australian study Investigators reviewed the medical records of 14 179 admissions to 28 hospitals in New South Wales and South Australia in 1995. An adverse event occurred in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9% 51% of adverse events were considered to have been preventable.

Australian study

Investigators reviewed the medical records of 14 179 admissions to 28 hospitals in New South Wales and South Australia in 1995.

An adverse event occurred in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9%

51% of adverse events were considered to have been preventable.

How common is medical error? The differences between the US and Australian results may reflect different methods or different rates Other, smaller studies (including one from Britain) show similar orders of errors There are few studies from outpatients or primary care

The differences between the US and Australian results may reflect different methods or different rates

Other, smaller studies (including one from Britain) show similar orders of errors

There are few studies from outpatients or primary care

How common is medical error? An evaluation of complications associated with medications among patients at 11 primary care sites in Boston. Of 2258 patients who had had drugs prescribed, 18% reported having had a drug related complication, such as gastrointestinal symptoms, sleep disturbance, or fatigue in the previous year.

An evaluation of complications associated with medications among patients at 11 primary care sites in Boston.

Of 2258 patients who had had drugs prescribed, 18% reported having had a drug related complication, such as gastrointestinal symptoms, sleep disturbance, or fatigue in the previous year.

Results of medical error In Australia medical error results in as many as 18 000 unnecessary deaths, and more than 50 000 patients become disabled each year. In the United States medical error results in at least 44 000 (and perhaps as many as 98 000) unnecessary deaths each year and 1 000 000 excess injuries.

In Australia medical error results in as many as 18 000 unnecessary deaths, and more than 50 000 patients become disabled each year.

In the United States medical error results in at least 44 000 (and perhaps as many as 98 000) unnecessary deaths each year and 1 000 000 excess injuries.

Types of error About half of the adverse events occurring among inpatients resulted from surgery. Next come Complications from drug treatment therapeutic mishaps diagnostic errors were the most common non-operative events. In the Australian study cognitive errors, such as making an

About half of the adverse events occurring among inpatients resulted from surgery.

Next come

Complications from drug treatment

therapeutic mishaps

diagnostic errors were the most common non-operative events. In the Australian study cognitive errors, such as making an

Types of error Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.

Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.

Which patients are most at risk? Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery Those with complex conditions Those in the emergency room Those looked after by inexperienced doctors Older patients

Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery

Those with complex conditions

Those in the emergency room

Those looked after by inexperienced doctors

Older patients

How dangerous is health care? Less than one death per 100 000 encounters Nuclear power European railroads Scheduled airlines One death in less than 100 000 but more than 1000 encounters Driving Chemical manufacturing More than one death per 1000 encounters Bungee jumping Mountain climbing Health care

Less than one death per 100 000 encounters

Nuclear power

European railroads

Scheduled airlines

One death in less than 100 000 but more than 1000 encounters

Driving

Chemical manufacturing

More than one death per 1000 encounters

Bungee jumping

Mountain climbing

Health care

Why do errors happen? All humans make errors: indeed, “the ability to make mistakes” allows human beings to function Most of medicine is complex and uncertain Most errors result from “the system”--inadequate training, long hours, ampoules that look the same, lack of checks, etc Healthcare has not tried to make itself safe

All humans make errors: indeed, “the ability to make mistakes” allows human beings to function

Most of medicine is complex and uncertain

Most errors result from “the system”--inadequate training, long hours, ampoules that look the same, lack of checks, etc

Healthcare has not tried to make itself safe

How to think of error? An individual failing Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis It will not solve the problem--it will probably in fact make it worse because it fails to address the problem Doctors will hide errors May destroy many doctors inadvertently (the second victim)

An individual failing

Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis

It will not solve the problem--it will probably in fact make it worse because it fails to address the problem

Doctors will hide errors

May destroy many doctors inadvertently (the second victim)

How to think of error? A systems failure This is the starting point for redesigning the system and reducing error

A systems failure

This is the starting point for redesigning the system and reducing error

How to respond? Tactics Reduce complexity Optimise information processing checklists, reminders, protocols Automate wisely Use constraints for instance, with needle connections Mitigate the unwanted side effects of change with training, for example.

Reduce complexity

Optimise information processing

checklists, reminders, protocols

Automate wisely

Use constraints

for instance, with needle connections

Mitigate the unwanted side effects of change

with training, for example.

Building a safe healthcare system (from James Reason) Principles Policies Procedures Practices

Principles

Policies

Procedures

Practices

Building a safe healthcare system (from James Reason) Principles Safety is everybody’s business Top management accepts setbacks and anticipates errors safety issues are considered regularly at the highest level Past events are reviewed and changes implemented

Principles

Safety is everybody’s business

Top management accepts setbacks and anticipates errors

safety issues are considered regularly at the highest level

Past events are reviewed and changes implemented

Building a safe healthcare system (from James Reason) Principles After a mishap management concentrates on fixing the system not blaming the individual Understand that effective risk management depends on the collection, analysis, and dissemination of data Top management is proactive in improving safety--seeks out error traps, eliminates error producing factors, brainstorms new scenarios of failure

Principles

After a mishap management concentrates on fixing the system not blaming the individual

Understand that effective risk management depends on the collection, analysis, and dissemination of data

Top management is proactive in improving safety--seeks out error traps, eliminates error producing factors, brainstorms new scenarios of failure

Building a safe healthcare system (from James Reason) Policies Safety related information has direct access to the top Risk management is not an oubliette Meetings on safety are attended by staff from many levels and departments Messengers are rewarded not shot Top managers create a reporting culture and a just culture

Policies

Safety related information has direct access to the top

Risk management is not an oubliette

Meetings on safety are attended by staff from many levels and departments

Messengers are rewarded not shot

Top managers create a reporting culture and a just culture

Building a safe healthcare system (from James Reason) Policies Reporting includes qualified indemnity, confidentiality, separation of data collection from disciplinary procedures Disciplinary systems agree the difference between acceptable and unacceptable behaviour and involve peers

Policies

Reporting includes qualified indemnity, confidentiality, separation of data collection from disciplinary procedures

Disciplinary systems agree the difference between acceptable and unacceptable behaviour and involve peers

Building a safe healthcare system (from James Reason) Procedures -Training in the recognition and recovery of errors Feedback on recurrent error patterns An awareness that procedures cannot cover all circumstances; on the spot training Protocols written with those doing the job Procedures must be intelligible, workable, available

Procedures

-Training in the recognition and recovery of errors

Feedback on recurrent error patterns

An awareness that procedures cannot cover all circumstances; on the spot training

Protocols written with those doing the job

Procedures must be intelligible, workable, available

Building a safe healthcare system (from James Reason) Procedures Clinical supervisors train their charges in the mental as well as the technical skills necessary for safe and effective performance

Procedures

Clinical supervisors train their charges in the mental as well as the technical skills necessary for safe and effective performance

Building a safe healthcare system (from James Reason) Practices Rapid, useful, and intelligible feedback on lessons learnt and actions needed Bottom up information listened to and acted on And when mishaps occur Acknowledge responsibility Apologise Convince patients and victims that lessons learned will reduce chance of recurrence

Practices

Rapid, useful, and intelligible feedback on lessons learnt and actions needed

Bottom up information listened to and acted on

And when mishaps occur

Acknowledge responsibility

Apologise

Convince patients and victims that lessons learned will reduce chance of recurrence

James Reason’s bottom line Fallibility is part of the human condition We can’t change the human condition We can change the conditions under which people work

Fallibility is part of the human condition

We can’t change the human condition

We can change the conditions under which people work

Conclusions Human beings will always make errors Errors are common in medicine, killing tens of thousands We begin to know something about the epidemiology of error, but we need to know much more Naming, blaming and shaming have no remedial value

Human beings will always make errors

Errors are common in medicine, killing tens of thousands

We begin to know something about the epidemiology of error, but we need to know much more

Naming, blaming and shaming have no remedial value

Conclusions We need to design health care systems that put safety first (First, do no harm) We know a lot about how to do that It’s a long, never ending job

We need to design health care systems that put safety first (First, do no harm)

We know a lot about how to do that

It’s a long, never ending job