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Revised partipme lecture 2012presentationslides1 36


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  • 1. Prevention of Medical Errors 2012 Mary Mckay DNP, ARNP Assistant Professor University of Miami School of Nursing and Health Studies
  • 2. Scope of the Problem
    • The Institute of Medicine study- “ To Err is
    • Human”-1999 found
    • 44,000 - 98,000 Americans die in hospitals each year from medical errors
    • Medication related errors result in
    • 7,000 deaths each year.
    • $37.6 billion and 50 billion dollars in associated costs
  • 3. Over 10 years later Is Health Care Safer Today?
    • It is very Difficult to Assess due to:
    • Lack of universal reporting system
    • Under reporting
    • Lack of consensus regarding terminology/definitions of what constitutes an error
  • 4. Why are errors under reported?
    • 1. Historically a punitive approach has been
    • taken when an error occurs leading to fear of :
    • Loss of reputation
    • Loss of job
    • Disciplinary action by professional board
    • Malpractice
  • 5. Why are errors under reported?
    • 2. Difficult to use reporting systems
    • 3. Time constraints in order to
    • follow up
    • 4. Sweep it under the rug mentality- as long as no one was hurt no need to talk about it
  • 6. Increasing Awareness For Patient Safety
    • Several national and international initiatives involving patient safety promotion will be introduced in this presentation including:
    • Use of simulation
    • WHO Pre operative safety checklist
    • Institute for Healthcare Improvement Initiative
    • Joint Commission Patient Safety Goals
  • 7. The Use of Simulation and Safety
    • What are the benefits of learning through simulation?
    • Allows for learners to perform in an environment that is as close as possible to a real patient scenario
    • Learners acquire and practice skills in a safe environment
    • Mistakes made while training will not harm a real patient
    • An opportunity to improve patient safety thru teamwork
    • and critical event training.”( American Society of
    • Anesthesiologists, 2008). As a student at UMSONHS
    • you will have the opportunity to use simulation.
  • 8. Institute for Healthcare Improvement is currently addressing:
    • Adverse Drug Events (ADE)
    • Catheter-Associated Urinary Tract Infections (CAUTI)
    • Central Line Associated Blood Stream Infections (CLABSI)
    • Injuries from Falls and Immobility
    • Obstetrical Adverse Events
    • Pressure Ulcers
    • Surgical Site Infections
    • Venous Thromboembolism (VTE)
    • Ventilator-Associated Pneumonia (VAP)
    • Other Hospital-Acquired Conditions
    • Posted on: April 12, 2011
    • Institute for Health Care Improvement @
  • 9. The World Health Organization (WHO) Initiatives Include
    • Clean Care is Safer Care
    • Safe Surgery Saves Lives
    • WHO Safety Check list
  • 10. Joint Commission
    • The Joint Commission is an accrediting agency that supports safe quality patient care. They have developed a sentinel event policy and patient safety goals that will be discussed in more detail.
  • 11. Review of Common Terminology
    • Medical Error
    • Adverse Event
    • Near Miss
    • Sentinel Event
  • 12. What is a Medical Error ?
    • According to the Institute of
    • Medicine(1999) a medical error is
    • defined as “ the failure of a planned
    • action to be completed as intended or the use of a wrong plan to achieve an aim”.
  • 13. What is an ADVERSE EVENT ?
    • An event in which a negative outcome occurred as a result of medical intervention rather than from the underlying medical condition.
  • 14. What is a Near Miss ?
    • An event or situation that could have resulted in an accident, injury or illness ,but did not, either by chance or through timely intervention.
    • Warning sign
    • Increased reporting needed
  • 15. Case Study #1
    • A 55 year old man presented to an ER with fever. Following an assessment the MD ordered an IV antibiotic and an antifungal IV drug- Diflucan . The nurse requested the Diflucan from the pharmacy. A 50ml bottle of Diprivan (sedative hypnotic agent) was sent to the ER erroneously labeled as
    • “ Diflucan 100mg/ml”. The nurse noted the bottle contained an opaque solution rather than the usual clear plastic bag of Diflucan she was familiar with.
    • While she was initiating a phone call to the pharmacy for clarification, a MD demanded her immediate assistance.
    • Reference:
  • 16. Case Study
    • She returned to the patient and hung the
    • Diprivan via the patient’s central line. The IV
    • pump alarmed “air in line” almost immediately.
    • While removing the air from the line the nurse
    • was once again alerted to the discrepancy she
    • had noted earlier. She removed the Diprivan
    • and contacted the pharmacy. Fortunately, the
    • patient had not received any of the Diprivan yet.
  • 17. What Happened ?
  • 18. Near Miss
    • This is an example of a “Near Miss”
    • One of the contributing factors in this case was the fact the nurse was interrupted during the event. Interruptions and distractions increase errors.
  • 19. What is a Sentinel Event?
    • The Joint Commission developed a Sentinel Event Policy and database in 1996 of all reported events.
    • Used to analyze events to provide information to healthcare organizations to deter future occurrences.
    Joint Commission
  • 20. What is a Sentinel Event?
    • A sentinel event is defined as an unexpected occurrence involving death or serious physical, or psychological injury, or risk thereof
    • Sends a signal or warning that requires immediate attention
    • Is not synonymous with “medical error”
  • 21. Agency for Healthcare Research and Quality
  • 22. What is a Root Cause and Analysis ?
    • A process for identifying the causative factors involved in the occurrence of a sentinel event
    • A root cause is the most basic reason for the failure or inefficiency of a process
    • Focuses primarily on systems/processes, and human factors
  • 23. Root Cause and Analysis
    • Often there are numerous root causes
    • Process must be conducted using a team approach- those involved in the incident must be included
    • A sequence of events or timeline must be established
    • Goal is to generate specific prevention strategies to reduce future errors
  • 24. Joint Commission Identified Root Causes of Sentinel Events for All Categories
    • Communication
    • Orientation/Training
    • Patient Assessment
    • Availability of information
    • Staffing levels
    • Physical environment Issues
  • 25. Joint Commission Identified Root Causes of Sentinel Events
    • Lack of Continuum of care
    • Competency/ Credentialing
    • Procedural compliance
    • Alarm systems
    • Organizational Culture
    • Another method to prevent errors
    • Process applied prior to actual error
    • Examines a system/process for possible high risk points of error
    • Possibly redesign the process to eliminate chance of failure
    • Pilot test
    • Implement the process
    • Reevaluate the possible risk of errors
    • Institute precautions if needed
  • 27. Example of FMEA
    • One potential failure mode includes medications with similar names. The institution can perform a failure modes and effect analysis prior to using the medication. The analysis involves identifying what errors could occur in that process, the significance of the errors and measures to prevent those errors. In the similarly named medications example, the institution may choose to utilize another drug, provide additional labeling alerts or ensure proper storage to prevent potential errors.
  • 28. Why Do Errors in Health Care Occur ?
    • “ Medical errors most often result from a
    • complex interplay of multiple factors. Only
    • rarely are they due to the carelessness or
    • misconduct of single individuals”
    • L. Leape, MD.
    • COMPLEXITY - A more complex system will have many steps involved which increases the risk of error. Many of the systems or processes involved in patient care have numerous steps. For example the process of administering medications involves multiple steps. Each of these steps presents an opportunity for errors.
  • 30. Why do Systems Fail?
    • VARIABILITY- Systems or processes that involve unpredictable or changing input have a greater failure rate. In health care, patients are unique and require individualization . While the process of administering medications may have universal steps( 8 Rights), there are some steps that are patient dependant such as correct dose range. The more variability present in a system or process the chance for errors is increased .
  • 31. Why do Systems Fail?
    • Inconsistency: A system or process that lacks standardization carries an increased risk for error. The use of standardization increases consistency and thus decreases errors .
    • Time Constraint: When individuals rush a process more errors are likely to occur.
  • 32. Why do Systems Fail?
    • HUMAN INTERVENTION- While most errors are system failures, human intervention may also play a role. Any system that depends on humans as part of the process has an increased risk for errors. One common misconception is that by telling someone to be more careful errors will be reduced. The reality is that healthcare providers are for the most part very careful and conscientious. One specific problem in healthcare is the over reliance on memory to prevent error. A more effective approach is to design systems or processes that provide prompts or the use of checklists.
  • 33. Why do Systems Fail?
    • HIEARCHICAL CULTURE - An environment that operates under the “Captain of the ship is always correct” or “ I’m in charge do as I say” rule is not conducive to questioning consistencies. If someone is afraid to raise questions there is an increased risk for errors. Individuals must trust that they will not be penalized for questioning inconsistencies.
    • TIGHT COUPLING -A tight coupled system involves many steps that follow closely and so if an error occurs it can not be detected prior to the next step in the process.
  • 34. Types of System Errors/Failures
    • Active errors/failures involve personnel and parts of the health care system that are in direct contact with the patient.
    • Their actions may result in errors that have a direct impact on patient safety
    • Referred to as errors occurring at the sharp end. Reason, JT. (1990). Human Error. New York, NY:Cambridge University
  • 35. Types of System Errors/Failures
    • Latent errors/failures involve individuals such as managers, administrators and policy makers
    • Their actions or decisions may lead to a negative impact on patient safety. Tend to be less obvious.
    • Referred to as errors occurring at the blunt end
    • Reason, JT. (1990). Human Error. New York, NY:Cambridge University
  • 36. Types of System Errors/Failures Blunt End Sharp End Latent Active