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Medical Error

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Medical Error

  1. 1. Methods in Reducing Medical Errors Introduction Stephen Stripe MD, FAAFP Shirley Cole-Harding PhD Vicki Michels PhD
  2. 2. Historical Prospective <ul><li>Nov. 1999 IOM Report, “To Err is Human” </li></ul><ul><ul><li>Called for; </li></ul></ul><ul><ul><ul><li>Research into causes and solutions </li></ul></ul></ul><ul><ul><ul><li>Enhanced Reporting of Errors </li></ul></ul></ul><ul><ul><ul><li>Increased Expectations for Performance </li></ul></ul></ul>
  3. 3. Historical Perspective: Agency for Healthcare Research and Quality <ul><li>Probability of: </li></ul><ul><li>Acquiring AIDS from single unit of blood </li></ul><ul><li>All heads on 20 consecutive coin tosses </li></ul><ul><li>Death airline accident </li></ul><ul><li>Death general anesthesia </li></ul><ul><li>Death MVA </li></ul><ul><li>Preventable Hospital Deaths </li></ul>
  4. 4. Historical Perspective <ul><li>July 2006 IOM Report </li></ul><ul><ul><li>1.5 million medication injuries/year </li></ul></ul><ul><ul><li>$3.5 Billion in hospital costs/year </li></ul></ul>
  5. 5. DEFINING ERRORS <ul><li>Adverse Error (AE)- “an injury that results from medical error” </li></ul><ul><li>Preventable AE </li></ul><ul><li>Potential AE – “near miss” or “close call” </li></ul><ul><li>Serious error=Preventable + Potential AE </li></ul>
  6. 6. Tracking Errors <ul><li>Brennan et al. (1991) </li></ul><ul><ul><li>30,121 charts reviewed, NYS 1984 </li></ul></ul><ul><ul><li>Results </li></ul></ul><ul><ul><ul><li>3.7% with AE </li></ul></ul></ul><ul><ul><ul><ul><li>1% negligent care </li></ul></ul></ul></ul><ul><ul><ul><ul><li>51.2% of those with AEs died. </li></ul></ul></ul></ul><ul><ul><ul><li>Risk Factors </li></ul></ul></ul><ul><ul><ul><ul><li>Age > 64 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>High risk surgery </li></ul></ul></ul></ul>
  7. 7. Tracking Errors <ul><li>Leape et al. (1991) </li></ul><ul><ul><li>Types of Error </li></ul></ul><ul><ul><ul><li>Operative =47.7% </li></ul></ul></ul><ul><ul><ul><li>Non-operative=52.3% </li></ul></ul></ul><ul><ul><ul><ul><li>Medication related=19.4% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Diagnostic mishap=8.1% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Therapeutic mishap=7.5% </li></ul></ul></ul></ul>
  8. 8. Tracking Errors <ul><li>Bates et al., ( 1995) </li></ul><ul><ul><li>Chart review and self-report on medical and surgical units </li></ul></ul><ul><ul><li>Results; </li></ul></ul><ul><ul><ul><li>6.5% ADE(1.8% preventable) </li></ul></ul></ul><ul><ul><ul><li>5.5% with potential ADE </li></ul></ul></ul><ul><ul><ul><li>Rate highest in ICU </li></ul></ul></ul><ul><ul><ul><li>42% of preventable ADEs life threatening or serious </li></ul></ul></ul><ul><ul><ul><ul><li>56% ordering </li></ul></ul></ul></ul><ul><ul><ul><ul><li>24% administration </li></ul></ul></ul></ul>
  9. 9. Tracking Errors <ul><li>Cognitive errors in malpractice suits </li></ul><ul><ul><li>state and federal courts U.S 8 th Circuit Court of Appeals Region </li></ul></ul><ul><ul><li>In 59% of the cases cognitive errors could be identified </li></ul></ul><ul><li>(Stripe et al. 2006) </li></ul>
  10. 10. Tracking Errors <ul><li>Adverse Events (AE) Reporting </li></ul><ul><ul><li>Self-report 0.04% </li></ul></ul><ul><ul><li>Computer monitoring 1.7% </li></ul></ul><ul><ul><li>Query clinicians 0.6-4.7% </li></ul></ul><ul><ul><li>Chart review 3.7-16.7% </li></ul></ul><ul><ul><li>Query+chart review 6.5% </li></ul></ul><ul><ul><li>Direct observation 17.7-100% </li></ul></ul>
  11. 11. Methods in Reducing Medical Errors Systems Approaches Stephen Stripe MD, FAAFP Shirley Cole-Harding PhD Vicki Michels PhD
  12. 12. Systems Approach <ul><li>“ Medical care relies on the integrated efforts of a complex network of people and support services.” </li></ul><ul><li>(Cosby & Crosskerry, 2003, p. 73) </li></ul><ul><li>“ Humans err. We’re made that way.” </li></ul><ul><li>“ Errors are attributes of systems” </li></ul><ul><li>“ Errors result from a confluence of causes” </li></ul><ul><li>(Weingart, 2006) </li></ul><ul><li>“ We can’t change the human condition, but we can change the conditions under which humans work.” (Reason, 2000) </li></ul>
  13. 13. Systems Approach <ul><li>“ Recognizing that medical errors are the fault of systems and not of individuals, (QuIC, 2000) </li></ul><ul><li>the purpose of hearing from this panel was to identify how improving patient safety can be a health care system-wide endeavor. …Some common themes raised by this panel were: confidentiality and protection, human factors, organizational/cultural issues, reporting systems, use of technology, and training of providers.” </li></ul>
  14. 14. What defines a system? <ul><ul><li>Setting </li></ul></ul><ul><ul><ul><li>ED, hospital </li></ul></ul></ul><ul><ul><li>People </li></ul></ul><ul><ul><ul><li>Physicians </li></ul></ul></ul><ul><ul><ul><li>Nurses </li></ul></ul></ul><ul><ul><ul><li>Pharmacists </li></ul></ul></ul><ul><ul><ul><li>Technicians </li></ul></ul></ul><ul><ul><ul><li>Administrators </li></ul></ul></ul><ul><ul><li>Support systems </li></ul></ul><ul><ul><ul><li>Radiology, laboratory, e.g. </li></ul></ul></ul><ul><ul><li>Organization </li></ul></ul><ul><ul><li>(Cosby & Croskerry, 2003) </li></ul></ul>
  15. 15. Systems Error People Support systems Setting Administration
  16. 16. Overview of Systems Theory <ul><li>Sources of error </li></ul><ul><ul><li>System problems </li></ul></ul><ul><ul><ul><li>even if human error is a factor </li></ul></ul></ul><ul><ul><li>Inadequate infrastructure to support high-tech medical care </li></ul></ul><ul><ul><li>Teamwork failure </li></ul></ul><ul><ul><li>Inadequate information networks </li></ul></ul><ul><ul><li>Equipment failure </li></ul></ul><ul><li>(Cosby & Croskerry, 2003) </li></ul>
  17. 17. Settings <ul><li>Sources of problems </li></ul><ul><li>The ED </li></ul><ul><ul><li>Overloaded, understaffed </li></ul></ul><ul><ul><li>High-acuity </li></ul></ul><ul><ul><li>Rapid decision making </li></ul></ul><ul><ul><li>Need rapid interventions </li></ul></ul><ul><ul><li>(Cosby & Croskerry, 2003) </li></ul></ul>
  18. 18. Teamwork <ul><li>Sources of problems </li></ul><ul><li>Segregation of medical personnel during training </li></ul><ul><li>Hierarchies </li></ul><ul><li>Lack of cross-checking </li></ul><ul><li>Lack of communication/information sharing </li></ul><ul><li>Lack of task sharing </li></ul><ul><li>Lack of coordination </li></ul><ul><ul><li>(Cosby & Croskerry, 2003) </li></ul></ul>
  19. 19. Support Systems <ul><li>Design flaws in medication delivery </li></ul><ul><ul><li>Naming, packaging, labeling </li></ul></ul><ul><ul><li>Handwriting </li></ul></ul><ul><ul><li>Matching staffing with demand </li></ul></ul><ul><ul><li>Delivery systems </li></ul></ul><ul><li>(Weingart, 2006) </li></ul>
  20. 20. Systems solutions <ul><li>Recognize latent (systems) error is a component of most errors </li></ul><ul><li>Encourage reporting of error </li></ul><ul><li>Promote teamwork </li></ul><ul><li>Prevent medication errors </li></ul><ul><li>Improve information technology </li></ul><ul><li>Address equipment problems </li></ul><ul><li>Consider human factors in equipment design </li></ul><ul><ul><li>(Cosby & Croskerry, 2003) </li></ul></ul>
  21. 21. Systems solutions <ul><li>Simplify and standardize </li></ul><ul><li>Reduce handoffs </li></ul><ul><li>Use constraints and forcing functions </li></ul><ul><li>Build in appropriate redundancy </li></ul><ul><li>Improve access to information </li></ul><ul><li>Adopt best practices </li></ul><ul><li>Take care of the system </li></ul><ul><li>( W eingart, 2006) </li></ul>
  22. 22. A Systems Solution <ul><li>Computerized Physician Order Entry </li></ul><ul><li>55% reduction in errors in serious medication errors </li></ul><ul><li>Specific benefits </li></ul><ul><ul><li>Streamlines ordering </li></ul></ul><ul><ul><li>Information needed at hand </li></ul></ul><ul><ul><li>Dosage guidance available </li></ul></ul><ul><ul><li>Checks performed </li></ul></ul><ul><li>(Bates, 2006) </li></ul>
  23. 23. A Systems Solution <ul><li>Problems with this CPOE system </li></ul><ul><li>Lessons </li></ul><ul><ul><li>Systems must be modified in response to problems occurring on implementation </li></ul></ul><ul><ul><li>Software alone is insufficient </li></ul></ul><ul><ul><li>Rapid introduction may cause problems </li></ul></ul><ul><ul><li>Must be implemented well </li></ul></ul><ul><ul><li>Must have proper decision support </li></ul></ul><ul><ul><li>Must be monitored </li></ul></ul><ul><ul><li>Changes must be made in response to problems </li></ul></ul><ul><li>(Bates, 2006) </li></ul>
  24. 24. Methods in Reducing Medical Errors Individual Approaches Stephen Stripe MD, FAAFP Shirley Cole-Harding PhD Vicki Michels PhD
  25. 25. Individual Approaches <ul><li>Introduction </li></ul><ul><ul><li>Systems made up of individuals </li></ul></ul><ul><ul><li>Individual decisions create medical error </li></ul></ul><ul><ul><li>Providing education will reduce medical error </li></ul></ul>
  26. 26. Individual Approach Theory <ul><li>Factors affecting decision making </li></ul><ul><ul><ul><li>Cognitive processes </li></ul></ul></ul><ul><ul><ul><li>Situational influences </li></ul></ul></ul><ul><ul><ul><li>Personality traits </li></ul></ul></ul>
  27. 27. Individual Approach Theory <ul><li>Cognitive Processes </li></ul><ul><ul><li>Development of Schemas </li></ul></ul><ul><ul><ul><li>Experience </li></ul></ul></ul><ul><ul><ul><li>Observations </li></ul></ul></ul><ul><ul><li>Benefits of Schemas </li></ul></ul><ul><ul><ul><li>Efficiency </li></ul></ul></ul><ul><ul><li>Cost of Schemas </li></ul></ul><ul><ul><ul><li>Biases </li></ul></ul></ul>
  28. 28. Individual Approach Theory <ul><ul><li>Type of Schemas </li></ul></ul><ul><ul><ul><li>Heuristics </li></ul></ul></ul><ul><ul><ul><ul><li>Representative </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Probability of occurring </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Availability </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Recent exposure to similar case </li></ul></ul></ul></ul></ul>
  29. 29. Individual Approach Theory <ul><ul><li>Biases created by schemas </li></ul></ul><ul><ul><ul><li>Confirmation bias </li></ul></ul></ul><ul><ul><ul><li>Fundamental attribution error </li></ul></ul></ul><ul><ul><ul><li>Recency effect </li></ul></ul></ul><ul><ul><ul><li>Commission bias </li></ul></ul></ul><ul><ul><ul><li>Ommission bias </li></ul></ul></ul><ul><ul><ul><li>Gender biases </li></ul></ul></ul><ul><ul><li>(Crosskerry, 2002) </li></ul></ul>
  30. 30. Individual Approach Theory <ul><li>Situational Factors </li></ul><ul><ul><li>Loss of situational awareness </li></ul></ul><ul><ul><li>Personal situational factors </li></ul></ul><ul><ul><ul><li>Illness </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><li>Stress </li></ul></ul></ul><ul><ul><ul><li>Alcohol or other substance use </li></ul></ul></ul><ul><ul><ul><li>Fatigue, hunger </li></ul></ul></ul><ul><ul><ul><li>Emotions </li></ul></ul></ul><ul><ul><li>External Pressures </li></ul></ul>
  31. 31. Individual Approach Theory <ul><li>Personality Traits </li></ul><ul><ul><li>Antiauthority </li></ul></ul><ul><ul><li>Macho </li></ul></ul><ul><ul><li>Impulsive </li></ul></ul><ul><ul><li>Invulnerability </li></ul></ul><ul><ul><li>Resignation </li></ul></ul>
  32. 32. Individual Solutions <ul><li>Improving meta-cognitive skills </li></ul><ul><ul><li>Educate about cognitive processes </li></ul></ul><ul><ul><li>Educate about cognitive errors </li></ul></ul><ul><ul><li>Develop strategies to prevent cognitive errors </li></ul></ul><ul><ul><li>(Crosskerry et al., 2000) </li></ul></ul>
  33. 33. Individual Solutions <ul><li>Modified Aviation Prevention Model </li></ul><ul><ul><li>Stripe, Cole-Harding, & Michels </li></ul></ul><ul><li>Increase awareness of situational factors affecting decision making </li></ul><ul><li>Increase awareness of personality on decision making </li></ul>
  34. 34. Assessment of Models <ul><li>Improving meta-cognitive skills </li></ul><ul><ul><li>Curriculum for model well laid out </li></ul></ul><ul><ul><li>(Cosby & Croskerry, 2000;Croskerry, et al., 2000) </li></ul></ul><ul><ul><li>No systematic research to assess effectiveness </li></ul></ul><ul><li>Modified Aviation Prevention Model </li></ul><ul><ul><li>Curriculum well laid out </li></ul></ul><ul><ul><li>Pilot study showed a 40% decrease in error for family medicine residents who received Modified Aviation Prevention Training. </li></ul></ul><ul><ul><ul><li>Only pre and post test, more research needed </li></ul></ul></ul>
  35. 35. Methods in Reducing Medical Errors Integrated Model Stephen Stripe MD, FAAFP Shirley Cole-Harding PhD Vicki Michels PhD
  36. 36. Integrated Models <ul><li>Commercial Aviation Model </li></ul><ul><li>Combined Systems and Cognitive Approach </li></ul><ul><ul><li>Checklists </li></ul></ul><ul><ul><li>Scheduled maintaince </li></ul></ul><ul><ul><li>Simulator training on a scheduled calendar for every flight officer </li></ul></ul><ul><ul><li>Cognitive reviews on a scheduled calendar for every flight officer </li></ul></ul>
  37. 37. Integrated Models <ul><li>Aviation Model Research Results </li></ul><ul><ul><li>Safest industry in the world involving high risk activity </li></ul></ul><ul><ul><li>0.232 incidents or accidents/100,000 flight hours </li></ul></ul><ul><ul><li>Death in airline accident just greater than the odds of 20 consecutive coin tosses coming up all heads </li></ul></ul>
  38. 38. Medical Model <ul><li>Combined Systems and Cognitive Approach </li></ul><ul><li>Checklists </li></ul><ul><li>Standard routine orders; (pneumonia, acute coronary syndrome, etc.) </li></ul><ul><li>Scheduled maintenance training </li></ul>
  39. 39. Medical Model <ul><li>EMR </li></ul><ul><li>Prepackaged medications </li></ul><ul><li>Cognitive review on a scheduled calendar for every physician, nurse, midlevel etc. </li></ul>
  40. 40. Medical Model <ul><li>Pilot study showed a 40% decrease in error for family medicine residents who received Modified Aviation Prevention Training. </li></ul><ul><li>55% with at least one systems approach </li></ul><ul><li>What would the decrease in error be with a combined approach? </li></ul>
  41. 41. Medical Model
  42. 42. References <ul><li>Bates, D.W., The Patient Safety Imperitive, 2006. </li></ul><ul><li>Bates et al., JAMA 1995: 274;29-34 </li></ul><ul><li>Brennan et al. NEJM 1991: 324:370-6 </li></ul><ul><li>Cosby, K.S. & Croskerry, P. Acad. Emerg. Med. 2003: 10; 69-78 </li></ul><ul><li>Croskerry, P. Acad. Emerg. Med. 2000; 7;1223-1231 </li></ul><ul><li>Croskerry, P., Wears, R., & Binder, L., Acad. Emerg. Med., 2000:7;11194-1200. </li></ul><ul><li>Leape et. Al. NEJM 1991: 324:377-84 </li></ul><ul><li>Stripe, S., et al., JABFM, 2006 </li></ul><ul><li>Weingart, S.N. The Patient Safety Imperitive, 2006. </li></ul>

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