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Err is human ....how could we minimize the preventable medical errors in our healthcare organization

Err is human ....how could we minimize the preventable medical errors in our healthcare organization

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  • 1. Dr Inas Alassar CPHQ
  • 2.  “Quality” means those features of products which meet customer needs and thereby provide customer satisfaction. The purpose of such higher quality is to provide greater customer satisfaction and, one hopes, to increase income. JURAN …
  • 3.  "Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction, and skillfull execution. It represents the wise choice of many alternatives. " William A. Foster,
  • 4.  IOM : Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
  • 5.  Measurable quality : can be defined objectively as compliance with, or adherence to, standards / Risk / cost .
  • 6.  2. Appreciative quality is the excellence beyond minimal standards and criteria, requiring judgments of skilled, experienced practitioners and sensitive, caring persons.  Experience/ ethics / peer review .
  • 7.  3. Perceptive quality : is that degree of excellence that is perceived and judged by the recipient or the observer of care rather than by the provider of care .
  • 8. Dimensions of Quality APPROPRIATENESS EFFICIENCY AVILABILITY PREVENTION / EARLY DETECTION COMPETENCY RESPECT AND CARE CONTINUITY SAFETY EFFECTIVENESS TIMELINESS EFFICACY
  • 9. Simply , Quality is ….. DOING THE RIGHT THINGS RIGHT FROM THE FIRST TIME AND IMPROVE IT EVERY TIME (CQI ). EFFICINECY EFFECTIVNESS APPROPRIATENESS
  • 10. S T E E E P
  • 11. Patient- and Family-Centered Care It s a series of values or principles: Dignity and Respect We listen to and honor patient and family perspectives and choices. We incorporate patient and family knowledge, values, beliefs, and cultural background into care planning and delivery. Information Sharing We communicate and share complete and unbiased information with patients and families in affirming and useful ways. Patients and families receive timely and accurate information so they may effectively participate in care and decision-making.
  • 12. Participation We encourage patients and families to participate in care and decision-making at the level they choose. Collaboration We invite patients and family members to work with our care providers and hospital leaders on policy and program development, execution, and evaluation; in health care facility design; and in professional education and care delivery. Access The care we provide is equitable and flexible, and is delivered as efficiently and timely as possible. Care Coordination We focus on the coordination of patient care and patient and family needs. Our health care teams are trained, and our systems are designed, to support transition, integration, and continuity of care. Emphasis is placed on continuous healing relationships.
  • 13. TO ERR IS HUMAN To err is to make a mistake… To make a mistake is human. Humans are not perfect. They make mistakes….! -An important point to realize about errors is that people never make them intentionally. -If someone does intentionally do the wrong thing, that is not an error but a premeditated ( planned ) act that should be recognized and addressed . -To understand why people make errors, first we need to understand normal mental functioning. -Cognitive psychologists have been studying this for decades and states that much of our mental functioning is automatic, rapid, and effortless. -At other times, we’re deeply engaged in solving problems – often a slow process involving a great deal of effort. - Both kinds of mental functioning are prone to error.
  • 14. A woman dies from untreated internal bleeding. A patient and her family are hit by a flurry of medical errors during a long hospital stay. A pharmacist is devastated when fatal mistakes occur on his watch. - In this topic , you’ll find out just how many people are affected by medical errors worldwide. -Finally, you’ll explore the reasons that providing safe care isn’t always easy in an environment in which powerful drugs, quick decisions, and persistent distractions are the norm.
  • 15. “First, do no harm.” This phrase is one of the most familiar tenets of the health care profession. If you poll a group of health care professionals, it is likely that most — if not all — would say they strive to embrace this motto in their practice. And yet, patients are inadvertently harmed every day in the health care system, sometimes with severe consequences
  • 16. Ensuring the patient s safety What does that mean, exactly? According to the World Health Organization, patient safety means offering "freedom…from unnecessary harm or potential harm associated with healthcare." A focus on safety can also reduce the severity of harm, should it occur
  • 17. Wrapping Your Head Around the Problem of Medical Error In 1999, the Institute of Medicine (IOM) released its landmark report, To Err Is Human, which stated that between 44,000 and 98,000 people die each year in US hospitals due to medical errors. That is more than the number of people who die in a given year from motor vehicle accidents, breast cancer, or AIDs.
  • 18. Since the 1999 IOM report, statistics from around the world continue to point to a very real and significant problem. Consider the following data: A study from 2000 showed that during one year, as many as 18,000 patients in Australia died from medical errors and more than 50,000 patients were disabled. Also in 2000, the Centers for Disease Control and Prevention (CDC) revealed that each year nearly 2 million patients in the United States get an infection while being treated for another illness or injury, and nearly 88,000 die as a direct or indirect result of this infection — adding nearly $5 billion to health care costs every year. A 2001 study showed that nearly 12 percent of hospital admissions in the United Kingdom involve some form of adverse event
  • 19. Why Are Errors Occurring?Why Are Errors Occurring? There are many answers to that question. The following are some of the more direct reasons: 1-Diagnosing and treating patients is incredibly complex. 2-Practitioners are often not adequately trained or prepared to deliver care as a well-integrated team.
  • 20. 3-Errors often occur as a result of flawed processes or systems of care — not because of negligent or irresponsible individuals. 4-The culture of safety — "the attitudes, beliefs, perceptions, and values that employees share in relation to safety"— that exists in most health care organizations is weak compared to many other high- risk, complex businesses such as the airline, petroleum, and nuclear power industries
  • 21. 5-As the practice of medicine advances, the complexity and the number of steps in any one care process also increase. -Delivering safe, appropriate, timely care to multiple patients, many of whom cannot read or understand complex medical terminology, is challenging - In addition, there is not one "right" way to practice medicine — although evidence-based medicine does support recommended practices for many care processes — and the science of medicine is filled with nuance and gray areas.
  • 22. Consider the following scenario Early one evening, at the beginning of a new shift, Janet needs to obtain blood samples for four of her patients. She collects one sample and, before she gets a chance to label it, she is called to help with another patient who is having an emergency. One of her colleagues called in sick and the unit is woefully understaffed, so she cannot give her blood sampling duties to someone else; she must put them on hold. Janet places the unlabeled specimen on the nurse's station with a sticky note nearby indicating the patient's name. She then goes to help with the other patient. After completing her work with the emergent patient, Janet returns to the nurse's station and discovers four unlabeled vials of blood and no sticky note. She realizes that another nurse on the unit is obtaining blood samples from his patients and was also called away. Now, both nurses have no idea which vials belong to which patients. Does it seem likely that a medical error is about to occur?
  • 23. Although the previous example illustrates some of the reasons why medicine is so complex — multiple patients, staffing issues, time-sensitive care, competing priorities — there are many others: -powerful drugs -highly technical equipment -rapid decisions made under time pressure -many caregivers and multiple “handoffs” -limited resources -highly acute illness and injuries -an environment full of distractions -variable patient volume
  • 24. In addition, here are more reasons: -There is not a high degree of agreement on what constitutes best practice within the medical field, despite the fact that evidence-based medicine does support many recommended practices. -What one health care organization feels is good practice, another may not. - When providers work in multiple institutions, this inconsistency may be problematic. -Diagnosis and treatment are often performed under some degree of uncertainty, requiring providers to make quick decisions based on insufficient information.
  • 25. •Medication monitoring, particularly in the outpatient setting, is quite challenging • because the patient goes home and may or may not take prescribed medications. •For a front-line practitioner, there are always new medications, new technologies, new procedures, and new research findings to assimilate.
  • 26. A New Perspective on Medical Error Historically, the medical profession has viewed medical errors as either an inevitable byproduct of complex care or a result of provider incompetence, often seeking to blame the providers involved in the error rather than examining the systems that may have failed. However, over the past ten years, health care organizations have begun to realize and accept that most errors cannot be linked to the performance of the individual and are instead the result of a series of system errors that work together to yield unsafe situations.
  • 27. The Provider Response to Error Patients and family members are not the only people to be affected by medical error. -The providers who experience those errors directly or indirectly are also affected. -As previously mentioned, the medical profession has historically expected its own practitioners to be perfect and if they would just try harder — free from mistakes. Within this context, when an error occurs, the logical extension is to blame the provider and "make sure" he or she never makes the same mistake again. This "blame and shame" approach has done little to further the cause of patient safety and, in fact, has taken us a step backward.
  • 28. Going Forward Safety has been defined by one industry leader as a “dynamic non-event.” -When things go right, nothing bad happens — nothing bad for the patient, nothing bad for the family, and nothing bad for the practitioner. But to make "nothing bad happen" requires a lot of good things to be done right.
  • 29. -To make dramatic improvements in patient safety will require the following commitments from both individuals working in health care and the organizations in which they work: -Acknowledge the scope of the problem of medical errors and make a clear commitment to redesign systems to achieve higher levels of safety. - -Recognize that most patient harm is caused by bad systems and not bad people, and therefore we must end our historic response to medical error, which has been saddled with finger-pointing and shame.
  • 30. -Acknowledge that individuals alone cannot improve safety; it requires everyone on the care team to work in partnership with one another and with patients and families. -To deliver the right care — for every patient, every time — requires a new way of thinking about error in medicine, and a new approach to preventing errors and harm. -To thoroughly understand and accept this approach, you must first gain a deeper appreciation for error causation and prevention .
  • 31. Assessment 1) What does patient safety mean, according to the World Health Organization? a) Freedom from unnecessary harm or potential harm associated with health care b) Freedom from errors or potential errors associated with health care c) Freedom from death associated with health care d) Receiving the most state-of-art care possible
  • 32. 1) What does patient safety mean, according to the World Health Organization? Correct Answer :a ) Freedom from unnecessary harm or potential harm associated with health care
  • 33. A Cenario …. James is a first-year surgery resident on his first pediatric rotation. His attending (consultant) asks him to start intravenous (IV) replacement fluids on a two-year-old who is having vomiting and diarrhea. -Having trouble remembering how to calculate fluid replacement rates for very small children, James asks Maria, a nurse on the unit. Maria responds, “You’re the doctor. It’s your job to decide this.” James picks a rate, 75 cc per hour, that puts the child into fluid overload. James is devastated.
  • 34. What is one of the reasons that this error occurred? a) James does not care about his patients’ safety b) There is an inadequate culture of safety and teamwork on the unit c) Best practice is not clearly understood in this patient’s case d) The complexity of care led to the error
  • 35. What is one of the reasons that this error occurred? Correct Answer : b) There is an inadequate culture of safety and teamwork on the unit We can assume that James cares about patient safety, like all health care providers. While errors do often occur due to the complexity of care or the lack of recognized best practice, in the case of IV fluid replacement, clear recommendations do exist for how to calculate these rates for children. In this case, when James asked for help, Maria, instead of being a team player, made James feel bad. James did not ask for help again but instead chose a rate, and an error occurred. Had there been a culture of safety fostering better teamwork, this error may well have been averted.
  • 36. Which of the issues listed below is NOT a reason that patients are harmed by medical errors? a) Practitioners often do not know how to work well in a team b) Recommended practice may vary from one institution to the next c) The modern health care setting is very complex d) Perfection is an unattainable goal, so harmful errors are to be expected e) New information takes a long time to be absorbed
  • 37. Which of the issues listed below is NOT a reason that patients are harmed by medical errors? Correct Answer : d) Perfection is an unattainable goal, so harmful errors are to be expected Some providers and health care systems have traditionally held the view that errors that cause harm are an inevitable part of providing care. However, when organizations design their systems to account for the likelihood of human error, it is possible to prevent those errors from causing harm.
  • 38. Stan, a 92-year-old man with mild dementia and atrial fibrillation (an abnormal heart rhythm), is admitted to the hospital with pneumonia. He is placed on appropriate antibiotics. His physicians note he is on warfarin, a blood thinner that may interact with the antibiotics, so they order an International Normalized Ratio (INR) test to check the degree to which his blood is thinned. Stan’s INR level looks fine one day after starting the antibiotics. He is ready to go home the next day, and the pharmacist on the unit recommends that Stan’s INR be checked in two or three days, as it may take some time for the interaction to fully develop. The discharging physician tells Stan and writes it on the discharge form. Stan forgets, and he cannot get an appointment with his clinic doctor for two weeks. One week later he has a small stroke due to a bleed in his brain. His INR at the time is found to be six (very high). 6) What is the MOST LIKELY outcome from this medical error? a) Trust improves among providers b) Patient satisfaction scores improve c) The pharmacist quits practicing d) Stan's family comes to the hospital for care
  • 39. 6) What is the MOST LIKELY outcome from this medical error? Correct Answer :c) The pharmacist quits practicing Patients and families are not the only “victims” of a medical error. Practitioners suffer as well. In fact, some practitioners leave their profession after committing errors leading to a death.
  • 40. 7) The “blame and shame” approach to medical error: a) Has moved patient safety forward b) Is an effective tool in the patient safety arsenal in certain circumstances c) Encourages people to report errors d) Reflects the understanding that human perfection is unattainable e) Adds to the negative effect of errors on providers
  • 41. 7) The “blame and shame” approach to medical error: Correct Answer : e) Adds to the negative effect of errors on providers By singling out the person who committed the mistake, the “blame and shame” approach fails to recognize that human perfection is unattainable. This approach also fails to reflect a systems-based understanding of how and why errors occur. The “blame and shame” approach adds to the harmful effects of errors by making providers feel as if they are failures, when in fact their actions are only the last in a long chain of errors leading to patient harm.
  • 42. What Is Considered an Unsafe Act? an unsafe act as “an error or a violation committed in the presence of a potential hazard. -According to Reason, unsafe acts may be categorized as either errors or violations. Errors may be further categorized as slips, lapses, and mistakes.
  • 43. Taking a Closer Look at Human Error In his book Human Error, James Reason said that errors can be divided into two types of failures: An action does not go as intended. An action goes as intended, but it’s the wrong one. The first type of failure, in which an action does not go as intended, is a so-called error of execution and may be further described as being either a slip — if the action is observable — or a lapse, if it is not.
  • 44. An example of a slip is accidentally pushing the wrong button on a piece of equipment — you and others can see that you pushed the wrong button. An example of a lapse is some form of memory failure, such as failing to administer a medication — no one can see your memory fail, so the error is not observable.
  • 45. The second type of failure, in which an action goes as intended but is the wrong one, involves a failure in planning. -This category of error, is known as a mistake. Here’s one example of a mistake: During a physical exam, a physician detects a lump in the right breast of a young, female patient. He’s convinced, based on the patient’s age and family history, that the lump could not be cancerous. He tells the patient that she probably has fibrocystic breasts — a common, non- cancerous condition — and he fails to pursue a more definitive diagnosis. Later, it’s discovered that the lump is in fact cancerous.
  • 46. Taking a Closer Look at Violations According to the World Health Organization (WHO), a violation is “a deliberate deviation from an operating procedure, standard or rules.” Although deliberate (done intentionally ) , violations are not necessarily the result of deviant behavior — “I know this is wrong, but I am going to do it anyway!”
  • 47. Let's look at an example At the end of the day, a respiratory therapist is late for picking up his children at day care. Because he is in a hurry, he speeds up (instead of slowing down) at two yellow lights, averaging about seven miles per hour above the posted speed limits along his route. He calls the day care facility on his cell phone while driving to let them know he will be 10 minutes late. These are all examples of violations, where the therapist either didn’t recognize the risk he was taking or felt the risk was justified. He is not a bad person, and he is not acting with conscious disregard for safety, but his actions are potentially unsafe.
  • 48. Human error in health care — slips, lapses, and mistakes — has the potential to harm patients, depending on the nature of the error. For example, you may “slip” and push an incorrect button that gives the patient an overdose of medication. -Likewise, you could have a “lapse” in memory, which causes you to give an incorrect dose of a life-saving medication. - You may make a “mistake” and misdiagnose a patient, giving him or her treatment that supports the misdiagnosis and leads to severe harm. Violations can also lead to patient harm. Consider the nurse who is working with a medication bar coding system that repeatedly breaks down. One day she is rushing to give a patient his medication and she skips using the bar coding system — figuring it's probably broken anyway. Although not intending to, she is putting the patient at risk.
  • 49. While we have been talking about how unsafe acts can lead to medical error, the term “medical error” is slightly misleading as it may give the impression that the kinds of errors that can occur in health care are unique to health care. This is not the case. What is different about health care is that there remains an element of “a culture of infallibility” — the idea that if we are good at our jobs, we cannot make mistakes — that denies the prevalence of error. And yet, error is very much a part of the human condition, so just trying to be perfect is not a rational or effective approach.
  • 50. In health care, serious errors that lead to patient harm are usually just like the previous situation—made up of one or more errors, and the opportunities to catch the errors are missed, allowing the consequences of the errors to slip through and cause harm. James Reason, an internationally known expert on error, has called this the Swiss cheese model.
  • 51. Reason proposed what is referred to as the “Swiss Cheese Model” of system failure. Every step in a process has the potential for failure, to varying degrees. The ideal system is analogous to a stack of slices of Swiss cheese. Consider the holes to be opportunities for a process to fail, and each of the slices as “defensive layers” in the process. An error may allow a proble to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer is a defense against potential error impacting the outcome.
  • 52. For a catastrophic error to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error. If the layers are set up with all the holes lined up, this is an inherently flawed system that will allow a problem at the beginning to progress all the way through to adversely affect the outcome. Each slice of cheese is an opportunity to stop an error. The more defenses you put up, the better. Also the fewer the holes and the smaller the holes, the more likely you are to catch/stop errors that may occur.
  • 53. Case Example #1: A 28-year-old, significantly obese woman goes to a clinic, complaining of calf pain that keeps getting worse. She tells her primary care provider that she thinks the pain is due to the new shoes she bought and her new commitment to walking and exercising more. She describes her pain to the doctor as a 10 on a scale of 1 to 10. The patient has no history of leg trauma, and her only medication is a birth control pill. After examining her, the doctor does not see anything unusual. The doctor prescribes ibuprofen and muscle relaxants, and instructs the woman to return to the clinic if her symptoms do not get better. A week later, the woman returns to the clinic complaining of chest pain and shortness of breath. Shortly after she transfers to the emergency department, she has a heart attack and is unable to be resuscitated. A post-mortem examination reveals a massive blockage in the artery that passes through her lung.
  • 54. Q What type of unsafe act, if any, does this case demonstrate? a) Slip b) Lapse c) Mistake d) Violation e) There is no unsafe act in this case
  • 55. Answer: C. In this example, the physician who assessed the patient made an error — in this case, a mistake. When the patient attributed her pain to new shoes and a new exercise routine, the physician took that available information and almost immediately concluded the patient had strained her calf muscle. Her symptoms were representative of many other patients he had seen who try to do too much exercise with too little preparation, too quickly. Anchored on his diagnosis, he thought more about the treatment than he did about what other factors might be causing her condition. While her obesity and use of birth control medication were both factors predisposing her to deep venous thrombosis (DVT) — blood clots — he became narrowly focused on next steps, not appreciating something he already knew: his physical exam was an unreliable strategy to determine the presence or absence of DVT. Several days later when the doctor was told by a colleague that his patient arrested in the emergency department, he knew almost immediately that the post-mortem was going to reveal a massive blockage. This example involves the concept of heuristics — cognitive shortcuts that allow for rapid, often unconscious decision making. Unfortunately, heuristics are also associated with cognitive biases that can be strong, but incorrect.
  • 56. Case Example #2: A 35-year-old man named John goes to the doctor for an initial visit and to get a referral for the ophthalmologist. After John's visit, the doctor is reviewing lab results for a different patient, Bill, and these results indicate that Bill is anemic and has blood in his stool, suggesting an ulcer or cancer. The doctor mistakenly enters a referral for John to the gastrointestinal (GI) lab for a colonoscopy. The referral states John has blood in his stool and mild anemia. John takes off work and prepares himself for the procedure. The day after his colonoscopy, John calls the provider who made the referral and asks when he was tested for blood in his stool and if he really needed the procedure. It is at this time that the doctor realizes that John has undergone an unnecessary procedure and that it has been ordered on the wrong patient.
  • 57. a) Slip b) Lapse c) Mistake d) Violation e) There is no unsafe act in this case What type of unsafe act, if any, does this case demonstrate?
  • 58. Answer: A. In this example, the physician made a slip. While reviewing Bill's lab results, the physician still had John’s electronic medical record open on the screen, and this medical record “captured” the next step in the physician's thought process, which was to make a referral to GI. It was not until John called the physician after the procedure was completed that the doctor recognized his error
  • 59. Case Example #3: A 70-year-old woman is having issues with her bladder and rectum that require surgery. During her surgery, a gauze sponge is placed in her vagina to control bleeding. The patient goes to the recovery area, from where she is to be directly discharged home. Her doctor writes an order to remove the sponge prior to her discharge but he does not communicate this to the patient or her daughter, who is there to support her mother. The male nurse assigned to the patient is working with a female nurse, who offers to remove the patient's Foley catheter — a tube inserted into the bladder to drain urine — and vaginal sponge. She removes the catheter but gets interrupted and does not remove the sponge. The male nurse assumes his colleague has removed the sponge and does not double check this. The patient follows up with her primary care provider seven days later because of vaginal pain and the sponge protruding from her vagina.
  • 60. Q What type of unsafe act, if any, does this case demonstrate? a) Slip b) Lapse c) Mistake d) Violation e) There is no unsafe act in this case
  • 61. Answer: B. In this example, there were several lapses in communication and execution of protocol that contributed to the patient's medical error. While her doctor wrote an order to remove the sponge prior to discharge, he did not communicate that order directly to the care team — as he typically did — nor to the patient or her daughter. It turns out that the physician had been up for 24 hours performing surgeries and simply forgot. That was the first lapse. The female nurse, who offered to remove the patient's Foley catheter and vaginal sponge for her male colleague, got interrupted in the process and remembered to remove the Foley catheter but not the sponge. This was the second lapse. The male nurse assigned to the patient assumed the female nurse had removed the sponge without actually verifying it. This was the third lapse.
  • 62. Case Example #4: In the course of one week at a mid-sized hospital and nearby primary care office, the following incidents took place: A 52-year-old woman, with a history of ulcers and bleeding in her gastrointestinal tract as a result of taking ibuprofen, is seen by a doctor at the primary care office. After examining her, the physician tries to prescribe ibuprofen to treat her condition. The medication order entry system issues an alert — the 25th one that day — and the physician ignores the alert without reviewing the patient's medical record, thinking the alert is likely to be another "false alarm." Behind on his schedule, he chooses to override the alert and prescribe the ibuprofen. After taking the medication, the patient develops bleeding in her gastrointestinal tract and has to be admitted to the hospital.
  • 63. A pharmacist dispenses 5 mg of Methotrexate — a drug used to treat certain types of cancer — instead of 5 mg of Methimazole — a drug used to treat an overactive thyroid condition. Before dispensing the medication, the pharmacist takes a quick look at the drug label, but mostly relies on the pharmacy storage location from which he pulls the drug and the first four letters of the drug's name to convince him he has the right medication for the patient. After taking the medication at home, the patient gets nauseated, calls the pharmacy, and returns the incorrect medication. An order is placed for "100 cc/hr" of normal saline IV solution for a 91-year-old inpatient on the medical-surgical floor. A nurse is busy tending to the needs of the patient — trying to locate some applesauce for her to eat and also setting up the IV solution. Since she is busy, the nurse does not bring the patient’s medical record into the room with her as required by policy, and she remembers the patient's IV dose as 1,000 cc/hr instead of 100 cc/hr. The patient receives 1,000 cc/hr for 2 hours before another nurse identifies the error at shift change.
  • 64. Q What type of unsafe act, if any, is represented throughout this case example? a) Slip b) Lapse c) Mistake d) Violation e) There is no unsafe act in this case
  • 65. Answer: D. An analysis of each of the incidents indicates that the unsafe acts were not human error per se, but violations. Although it’s easy to see why many of these violations occurred, they are violations nevertheless. The physician who ignored the medication order entry system alert without reviewing the patient's medical record made a conscious decision not to follow safe practice, convincing himself that it was another false alarm and succumbing to the time pressures of his busy schedule. The pharmacist who dispensed the wrong drug chose not to carefully read the label and compare it against the order he received, per protocol. Instead, he relied on the storage location of the drug and the first several letters of its spelling to dispense the medication. This was not the practice he had been taught. The nurse who overdosed the patient created a shortcut to facilitate getting her job done, making a decision not to bring the patient’s medical record into the room per hospital policy, and instead relying on her memory to safely administer the medication. This was not a simple slip or lapse in performance.
  • 66. By focusing on the individual as the cause of error, organizations isolate individual unsafe acts from the system context, which includes a multitude of complex processes, in which they occur. As a result, the pursuit of greater patient safety is seriously impeded by an approach that does not seek out and remove the error-provoking properties within the larger system of care. In other words, the health care profession's traditional approach to fixing medical error is not valid anymore, if ever it was. There is another, more effective way to prevent unsafe acts in health care. By focusing more on the conditions under which individual providers and care teams work, and by designing in workflow and defenses to avert errors, health care organizations can minimize the conditions that lend themselves to violations and put mechanisms in place to mitigate unsafe acts that may nevertheless occur. This “systems approach” can be quite successful in preventing medical error and making patients safe. Now That We Know About Unsafe Acts, What Can We Do About Them?
  • 67. Let s think about this … *Shifting to a systems view of safety within healthcare: a) Allows us to better identify and remove people who are unsafe b) Allows us to change the conditions under which humans work c) Is only realistic in the most complex care settings, such as ICUs d) Assumes that humans can be trained to make no mistakes e) Allows us to view unsafe acts as violations
  • 68. *Shifting to a systems view of safety within healthcare: Correct Answer :b) Allows us to change the conditions under which humans work Having a systems view of healthcare recognizes that humans are not perfect, and that systems have a significant role to play in safety. This view is applicable in all patient care settings, as all care settings these days are complex.
  • 69. After nine months, hand hygiene rates have significantly improved, but infection rates are only slightly better. Further data analysis reveals a previously unrecognized, significant explanation for the infection rate rise: providers are using antibiotics at a much higher rate in the hospital than is the norm for a hospital like theirs, especially for upper respiratory infections. The extra antibiotic use is predisposing patients to “super-infections” such as C. difficile. What intervention is most likely to be effective? a) Step up the hand-washing campaign b) Work with physician leaders to educate providers about the high infection rates and high antibiotic use rates c) Design a patient handout describing the risks of a C. difficile infection d) Change the physician incentives so that the physicians are penalized when they prescribe antibiotics
  • 70. What intervention is most likely to be effective? Correct Answer :b) Work with physician leaders to educate providers about the high infection rates and high antibiotic use rates The over-prescribing of antibiotics is an example of an error in planning, or a mistake. The physicians in this example are utilizing antibiotics more often than recommended, and may not be considering the risks of antibiotic overuse. The intervention should address the main issue of the way physicians develop plans for patient treatment.
  • 71. According to James Reason, an “unsafe act”: a) Is an error or a violation committed in the presence of a potential hazard b) Will always result in patient harm c) Includes slips, lapses, and blunders d) Is intentional on the part of the perpetrator
  • 72. According to James Reason, an “unsafe act”: Correct Answer: a) Is an error or a violation committed in the presence of a potential hazard James Reason calls unsafe acts errors or violations. They are not always intentional. Additionally, they can be further divided into slips, lapses, and mistakes.
  • 73. A Call to Action — What YOU Can Do Five Critical Behaviors to Improve Safety You are a critical link in the chain of patient safety and must not take that responsibility lightly. Here are five behaviors that any practitioner can do to improve safety for patients in his or her direct care: 1. Follow written safety protocols 2. Speak up when you have concerns 3. Communicate clearly 4. Don’t let yourself or others get careless 5. Take care of yourself
  • 74. Behavior One: Follow Written Safety Protocols Most, if not all, health care organizations have protocols in place that help preserve patient safety. -Some of these are standardized throughout the industry — for example, administering antibiotics before surgery — and some have been developed specifically for a particular organization — for example, using different color-coded stickers on the medical record to indicate a patient's risk for falls. - Protocols are often developed through the analysis of trended data or as a result of a single adverse outcome.
  • 75. Other examples of protocols that may be relevant to your work include the following: Two patient identifiers: Protocols that require two separate patient identifiers can help make sure you accurately identify a patient prior to the administration of a medication or the drawing of blood, for example. Alarm monitoring: These protocols ensure that physiologic monitoring systems intended to protect patients are not ignored or inappropriately inactivated. Specimen labeling and handling: These policies and procedures ensure specimens are not lost or incorrectly labeled, resulting in a repeat draw, a delay in diagnosis or treatment, or a “wrong-patient, -site, or - procedure” event. Equipment disinfection/sterilization: These procedures minimize the risk of infection caused by improperly disinfected or sterilized medical equipment and reusable devices. Hand washing and sanitizing: These procedures outline when, where, and how providers should wash their hands and help reduce the spread of infection, targeting one of the most significant areas of patient harm.
  • 76. Behavior Two: Speak Up When You Have Concerns There are several ways you can “speak up,” which can enhance the safety of the organization in which you work. Identify and report issues with policies and procedures. If a policy or procedure is not available, workable, intelligible, or correct, you should report it. As previously mentioned, working around issues with policies and procedures does nothing to help you protect your patients. Report unsafe working conditions, close calls, and adverse events.— organizations that consistently perform complex procedures safely and without error — that within these organizations staff members report errors, elaborate experiences regarding near misses to learn from them, and treat any lapse in performance as a symptom that something might be wrong with their system. They recognize that small errors can quickly lead to big ones, and when people’s lives are at stake, waiting for “big ones” can be too late.
  • 77. Verbalize concerns Perhaps the most difficult part of “speaking up” is doing it when it matters most. If you see another member of the health care team do something that puts the patient’s safety at risk, you must speak up. -In most cases, patients do not feel like they have a voice, or are not able to detect an impending catastrophe. - Without you, a patient may have no voice. Think about what you would want if you were in his or her shoes, and then do the right thing.
  • 78. Behavior Three: Communicate Clearly If there were one aspect of health care delivery an organization could work on that would have the greatest impact on patient safety, it would be improving the effectiveness of communication on all levels — written, oral, electronic . Between 1995 and 1996, a breakdown in communication was the number one root cause of sentinel events reported to the Joint Commission in the United States
  • 79. Listen to Your Patients Your patients know their bodies better than anyone. Whether asking about the reason for their visit, taking a history and physical, or probing to understand their values and expectations regarding a variety of treatment choices, listening to your patients is a critical activity — possibly the most critical — that you can do to preserve their safety. Check for Understanding Our health care lingo is complex, and many of our patients have challenges with health care literacy. Don’t let their misunderstanding of your conversation with them place them in harm’s way. Ask them to summarize in their own words what their condition is, what actions they must take to manage their care, and why those actions are important.
  • 80. Use SBAR SBAR is a structured communication technique developed by, Doug Bonacum. While serving on a US Navy submarine, Bonacum was taught how to structure information so that even a junior team member could easily share critical information with someone higher, ensuring prompt action. - Later in his career, as he listened to doctors and nurses express trouble sharing and understanding key facts about patients, he realized the military briefing techniques he had learned could be modified and applied to health care. Within this technique: S stands for “Situation” B stands for “Background” A stands for “Assessment” R stands for “Recommendation”
  • 81. SBAR is especially useful when you’re trying to communicate a complex set of facts so that the listener can make a decision. Consider the following interchange between a doctor and nurse using SBAR. Nurse Smith: Good morning, Doctor Adams. This is Amy Smith. Doctor Adams: Good morning, Ms. Smith. What can I do for you? Nurse Smith: Situation: I am calling about Mr. Gutierrez in Room 303. His breathing has become increasingly labored over the last four hours, and he is now quite short of breath.
  • 82. Background: Mr. Gutierrez is post-operative Day 3 from a hip replacement. He has a history of hypertension and congestive heart failure. He was doing well until today — both eating wise and working with physical therapy. Now his respiratory rate is 26, and his oxygen saturation is 93 percent. I am concerned, of course, about both of these. His lungs are crackly and he has taken in about a liter-and-a-half more fluid than he’s discharged. Assessment: My assessment is that he is fluid overloaded. Recommendation: I’d like to Hep Lock his IV (Note to student: Generally, a saline lock is used for lines in the arm, but it is sometimes referred to as a "Hep Lock" for historical reasons) and have you evaluate him as soon as possible. When can you come? Doctor Adams: I am on my way. You should expect me in Room 303 to evaluate Mr. Gutierrez in 15 minutes.
  • 83. Provide Read Backs Can you imagine an air traffic controller telling a pilot the name and number of the runway on which to land and not requiring the pilot to read back the name and number of the runway? Neither can we! Even restaurants practice read back with take-out orders. Read back should be used more prominently in health care. Write down and read back all verbal orders you receive to keep your patients safe!
  • 84. Behavior Four: Don’t Let Yourself or Others Get Careless Unless everyone in health care is willing to confront everyone else on every single rule violation, the risk of an adverse event will always be high. Most violations are not done with the intent to harm, but rather with the intent to get one’s job done, and without a thorough understanding of the potential consequences of the behavior. Because an individual can exhibit at-risk behavior at any time, every provider — including YOU — must be responsible for the quality of the behavioral choices he or she makes. In addition, to protect our patients, every provider needs to appropriately confront “drift” — a slow, incremental move away from safe actions — when he or she sees it in other members of the health care team.
  • 85. Behavior Five: Take Care of Yourself Have you ever gone to work when you were exhausted, feeling ill, or anxious about something? Of course, we all have done that and probably make a regular habit of it. However, going to work when you are not feeling your best can lead to patient harm. For example, it has been shown that cognitive performance after 24 hours without sleep is equivalent to performing with a blood alcohol level of 0.10. Stress can also degrade performance. Current research seems to indicate that stress may have its biggest negative effect on knowledge-based workers — that’s probably you! Stress is also a likely contributor toward tunnel vision, where one has an extremely narrow focus and loses sight of the bigger picture.
  • 86. Let s think about it …. Which of these is an example of using a systems-based approach to decrease the likelihood of unsafe acts? a) Implementing a system allowing nurses to report bad behaviors by physicians b) Posting the names of people who have violated the hand hygiene protocol in the break room c) Developing a system where a new nurse in the emergency department is always paired with an experienced nurse who has proven to be an effective mentor d) Sending warning letters to pharmacists who misfill prescriptions
  • 87. 1) Which of these is an example of using a systems-based approach to decrease the likelihood of unsafe acts? Correct Answer:c) Developing a system where a new nurse in the emergency department is always paired with an experienced nurse who has proven to be an effective mentor Reporting bad behavior, monitoring hand washing, and sending warning letters may all be important safety processes in some cases. However, these processes are centered around individual behavior, and they do not address systems issues that may contribute to the likelihood of unsafe acts. Developing a system to pair novice and experienced nurses does recognize that system design can help improve outcomes.
  • 88. After a team training system is implemented in an operating room (OR), a junior circulating nurse notices that a particular anesthesiologist goes missing from the OR at odd times, often seems sluggish, and occasionally slurs her words. Concerned that the physician might be impaired due to medication abuse, the nurse ponders what to do next. 4) What would be the most appropriate way for him to respond? a) Call the physician at home and warn her to stop abusing prescription medication b) Refuse to work with that physician in the future c) Talk to the medical director in confidence d) Warn his friends about working with that physician e) Start a rumor about the physician
  • 89. What would be the most appropriate way for him to respond? Correct Answer:c) Talk to the medical director in confidence The junior nurse should speak up now that he has a concern. Warning friends or refusing to work with this physician does not improve the situation for the entire hospital; nor does it protect the patients of this doctor. Speaking with the medical director or another person in authority is the best option in this difficult situation.
  • 90. 1) Errors always result in harm. a) True b) False
  • 91. 1) Errors always result in harm. Correct Answer :b) False
  • 92. What is a systems approach to addressing error? a) Recognizing that the design of systems and processes, not individuals, are the major reason for error b) Catching an error before it causes harm c) Using systems to identify errors
  • 93. What is a systems approach to addressing error? Correct Answer :a) Recognizing that the design of systems and processes, not individuals, are the major reason for error
  • 94. It is the highest form of self-respect to admit our errors and mistakes and make amends for them. To make a mistake is only an error in judgment, but to adhere to it when it is discovered shows infirmity of character. Dale turner