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the doctor's mistake
Eric REVUE, MD
European Society of Emergency Medicine (EuSEM)
French Society of Emergency Medicine (SFMU)
International Leadership Emergency Department Institute (IEDLI)
Head of the Emergency Department
and prehospital EMS (SMUR- SAMU 28)
Chartres (France)
erevue@ch-chartres.fr
@revue5
Real Case
• A 35 y-o man present to the ED
with his wife, for a “minor” head
trauma, after a fall when getting
out of a restaurant
• The patient is aggressive, seems
dizzy (he admit to drink a few) and
doesn't want any physical exam
despite a wound on the scalp..
• He wants to leave the ED
• His wife tells to the nurse that her
husband takes an oral
anticoagulant for AF..
• Despite many negotiations with the
couple, the patient left the ED …
• 4 hours later, the patient is admitted
in another hospital for urgent
neurosurgical evacuation a a severe
acute subdural hematoma ...
• The neurosurgeon calls the EP, is
upset and wants explanations : “how
could you discharge this patient ?”
• The EP minimize his mistake
“What, Why, Who, How”?
1. Analyze the situation
2. How could the ED avoid this mistake ?
3. How could we discuss with the doctor ?
Ishikawa fishbone
Potential Causes
Effect
Why ?
• People are fallible
• Emergency Physicians make mistakes, errors …
• EP may be tired, stressed, disturbed …
• Medicine is still treated as an art, not science
• Need to view the delivery of healthcare as a science
• how to catch mistakes before they reach the patient
SystemSystem FailureFailure LeadingLeading toto medicalmedical ErrorError
Lack of teamwork
Lack of Communication
Lack of protocol
Inadequate training
and supervision
Patient suffers
Inadequate conflicts
resolution
Process failures
System failures
Communication failures
Individual Behaviors Clinical judgment 59%
Narrow diagnostic focus
Delay in ordering
tests/referrals
Lack of patient monitoring
Misinterpretation of test
results
Reliance on negative
findings despite ongoing
symptoms
Documentation 24%
Clinical systems 18%
Communication 32%
Medical errors…
• Frequent
• Preventable
• Lack of staff competencies ?
• Mainly due to lack of
– Organization
– Coordination
– Check control
– Communication
• Every ED is concerned
• Risk is 10 X higher for hospitals without program to prevent it
Errors in emergency medicine:
1) Magnitude of emergency medical errors : surveillance
2) identify causal factors : clinical epidemiologic methods
3) Evaluate the effectiveness of interventions to reduce errors
Every doctor makes
mistakeshttp://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that
Kohn LT, Corrigan JM, Donaldson MS (Institute of Medicine). To err is human: building a safer health system. Washington DC: National Academy Press; 2000.
16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.
Communication
Principles of safe designPrinciples of safe design
• Standardization (protocols)
• Check lists
• Learn from our errors
– What happened
– Why
– What did you do to reduce risk
– How do you know it worked
• Apply principles to the team
• Regular and independent controls and
informations
Goals
• Define safety/risk/quality program
• Write clean plans/policies
• Use a measurement process
• Makes sure process improvement
happens
• Evaluate performance
Impact vs. Probability of risk/error
Control
Mitigate & Control
DO DON’T DO
Encourage the doctor (the team) Criticize
Positives points Focus on Negative points
Debriefing the doctor/the team Blame the doctor in front of the team
Be Calm ! Be upset
Respect ? Criticize, humiliate the doctor/ the team
Apply procedures “we always do it that way “
Meet the team Team A vs Team B
Communicate Keep and hide the fault/mistake
Sandwitch method
Don’t blame , never shame !
Risk Management Life Cycle
Culture
Identify and
prioritize risks
Evaluate
options
Evaluate
Performance
Goal
setting
Confirm
next
steps
Implement
Conclusions
• Risk Management program is essential in an ED
• Learn from Aviation safety principles
• Analyze the process of risk errors
• Standardize, protocols, checklists
• Beware lack of teamwork,
• Communication +++
• Training, simulation +++
• Learn from errors
Doctors make mistakes

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Doctors make mistakes

  • 1. the doctor's mistake Eric REVUE, MD European Society of Emergency Medicine (EuSEM) French Society of Emergency Medicine (SFMU) International Leadership Emergency Department Institute (IEDLI) Head of the Emergency Department and prehospital EMS (SMUR- SAMU 28) Chartres (France) erevue@ch-chartres.fr @revue5
  • 2. Real Case • A 35 y-o man present to the ED with his wife, for a “minor” head trauma, after a fall when getting out of a restaurant • The patient is aggressive, seems dizzy (he admit to drink a few) and doesn't want any physical exam despite a wound on the scalp.. • He wants to leave the ED • His wife tells to the nurse that her husband takes an oral anticoagulant for AF..
  • 3. • Despite many negotiations with the couple, the patient left the ED … • 4 hours later, the patient is admitted in another hospital for urgent neurosurgical evacuation a a severe acute subdural hematoma ... • The neurosurgeon calls the EP, is upset and wants explanations : “how could you discharge this patient ?” • The EP minimize his mistake
  • 4. “What, Why, Who, How”? 1. Analyze the situation 2. How could the ED avoid this mistake ? 3. How could we discuss with the doctor ? Ishikawa fishbone Potential Causes Effect
  • 5. Why ? • People are fallible • Emergency Physicians make mistakes, errors … • EP may be tired, stressed, disturbed … • Medicine is still treated as an art, not science • Need to view the delivery of healthcare as a science • how to catch mistakes before they reach the patient
  • 6. SystemSystem FailureFailure LeadingLeading toto medicalmedical ErrorError Lack of teamwork Lack of Communication Lack of protocol Inadequate training and supervision Patient suffers Inadequate conflicts resolution Process failures System failures Communication failures Individual Behaviors Clinical judgment 59% Narrow diagnostic focus Delay in ordering tests/referrals Lack of patient monitoring Misinterpretation of test results Reliance on negative findings despite ongoing symptoms Documentation 24% Clinical systems 18% Communication 32%
  • 7. Medical errors… • Frequent • Preventable • Lack of staff competencies ? • Mainly due to lack of – Organization – Coordination – Check control – Communication • Every ED is concerned • Risk is 10 X higher for hospitals without program to prevent it
  • 8. Errors in emergency medicine: 1) Magnitude of emergency medical errors : surveillance 2) identify causal factors : clinical epidemiologic methods 3) Evaluate the effectiveness of interventions to reduce errors Every doctor makes mistakeshttp://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that Kohn LT, Corrigan JM, Donaldson MS (Institute of Medicine). To err is human: building a safer health system. Washington DC: National Academy Press; 2000.
  • 9. 16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007. Communication
  • 10. Principles of safe designPrinciples of safe design • Standardization (protocols) • Check lists • Learn from our errors – What happened – Why – What did you do to reduce risk – How do you know it worked • Apply principles to the team • Regular and independent controls and informations
  • 11. Goals • Define safety/risk/quality program • Write clean plans/policies • Use a measurement process • Makes sure process improvement happens • Evaluate performance
  • 12. Impact vs. Probability of risk/error Control Mitigate & Control
  • 13. DO DON’T DO Encourage the doctor (the team) Criticize Positives points Focus on Negative points Debriefing the doctor/the team Blame the doctor in front of the team Be Calm ! Be upset Respect ? Criticize, humiliate the doctor/ the team Apply procedures “we always do it that way “ Meet the team Team A vs Team B Communicate Keep and hide the fault/mistake Sandwitch method Don’t blame , never shame !
  • 14. Risk Management Life Cycle Culture Identify and prioritize risks Evaluate options Evaluate Performance Goal setting Confirm next steps Implement
  • 15. Conclusions • Risk Management program is essential in an ED • Learn from Aviation safety principles • Analyze the process of risk errors • Standardize, protocols, checklists • Beware lack of teamwork, • Communication +++ • Training, simulation +++ • Learn from errors

Editor's Notes

  1. .
  2. without any physical exam, no CT scan …no documents, no painkillers ...
  3. Nous ne sommes pas des robots Nous faisons des erreurs (les signalons nous ?) Nous sommes dérangés, fatigués, stressés…. Nous ne sommes pas toujours vigilants Nous ne sommes pas toujours (jamais) entrainés
  4. en résumé : insuffisance ou d’un manque de culture commune de sécurité
  5. cad Emerg Med. 2000 Nov;7(11):1201-3.Errors in emergency medicine: research strategies.Kyriacou DN, Coben JH.SourceDivision of Emergency Medicine, Northwestern University Medical School, Chicago, IL 60611, USA. dkyriacou@aol.comAbstractMedical errors in emergency departments (EDs) may be an important "public health risk." Therefore, scientific public health approaches should be used to 1) assess the magnitude of emergency medical errors with surveillance methods, 2) identify causal factors of these medical errors with clinical epidemiologic methods, and 3) evaluate the effectiveness of interventions aimed at reducing or eliminating emergency medicine errors with health service research techniques. Since errors result from complex human-system interaction, research efforts should focus on actions taken by the patient, factors concerning the ED environment, and actions taken by health care workers. Other medical and nonmedical fields have already made great advancements in studying and reducing human error. Many of these advancements could readily be adapted to study emergency medical errors.
  6. Standardize Eliminate steps if possible Create independent checks Learn when things go wrong What happened Why What did you do to reduce risk How do you know it worked