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Preventing Medical Errors: A Team Approach

Preventing Medical Errors: A Team Approach. Safety Improvement and Error Reduction Through Understanding. Presented by: Cynthia A.Mikos, Esq. Cynthia A. Mikos, P.A. cmikos@camlaw.net www.camlaw.net. Objectives. All participants will be able to describe: Root cause analysis

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Preventing Medical Errors: A Team Approach

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  1. Preventing Medical Errors:A Team Approach Safety Improvement and Error Reduction Through Understanding Presented by: Cynthia A.Mikos, Esq. Cynthia A. Mikos, P.A. cmikos@camlaw.net www.camlaw.net

  2. Objectives • All participants will be able to describe: • Root cause analysis • Error reduction and prevention measures • Patient safety processes

  3. Additional Objectives for Nurses • Factors that impact the occurrence of medical errors • How to recognize error prone situations • Processes to improve outcomes • Responsibilities for reporting • Safety needs of special populations • Factors important for public education

  4. Additional Objective for Physicians • Identify the five most misdiagnosed conditions as established by the licensing board

  5. Additional Objectives for Physical Therapists • Education for physical therapists must also encompass: • Medical documentation and communication • Contraindications and indications of physical therapy and patient management • Pharmacological components of physical therapy and physical management.

  6. Caution • The information presented today is intended as a broad overview of error in healthcare, presented in good faith conformance with Florida statutory and administrative code requirements. This information is for educational purposes and should not be construed as legal advice. The information presented generally reflects the views of this particular author.

  7. Medical Error is a Public Health Nightmare • The burden of harm conveyed by the collective impact of all of our health care quality problems is staggering. (Chassen et al., 1998)

  8. Select Resources for Patient Safety Information • Agency for Healthcare Research and Quality www.ahrq.gov • Institute of Medicine of the National Academies www.iom.edu • The Joint Commission www.jointcommission.org • Institute for Safe Medication Practices www.ismp.org • National Patient Safety Foundation http://npsf.org/

  9. Error Definition • Multiple definitions and understandings of what constitutes medical error • IOM definition • Errors are failures of planned actions to be completed as intended (error of execution) or the use of wrong plans to achieve what is intended (error of planning) May be acts of commission or omission • Harm is not required

  10. Adverse Event Definition • Adverse events – injuries caused by medical intervention (not health condition of patient) • A large proportion of adverse events are the result of errors and are known as Preventable Adverse Events • Adverse drug event – any injury due to medication

  11. Who to Blame? • Individuals - who are faulty or weak • The system - an interdependent interaction of multiple human and non-human elements

  12. Human Contributions to Errors • Active failures – front line workers who operate the technology which interfaces with the patient • Latent conditions – factors in the system that are designed by humans but are not under the direct control of front-line workers

  13. Error Process • Organizational processes • Create error producing environment • Caregiver makes an error at human end of interface • Breaching of safety protocols • Bad outcome results

  14. People Factors in Error • Fatigue • Interruptions • Unfamiliar situations • Miscommunication • Heavy workload

  15. Process Factors in Error • Variable input • Complexity • Inconsistency • Tight coupling

  16. Collection of Error Data • 27 states with systems for hospitals to report adverse events (26 mandatory) • Sentinel event reporting through JCAHO • Voluntary reporting through various organizations such as the Institute for Safe Medication Practices

  17. Reportable Events • Vary by state and accrediting bodies • Tension between accountability and improving patient safety • Florida definitions of reportable events- • Slightly differ by setting where the adverse incident occurs • Hospital or ambulatory surgery center • Physician office • Nursing home

  18. Florida’s Mandatory Reporting for Hospitals • Adverse Incident- an event over which health care provider exercises control … which: • Results in 1) death, 2) brain or spinal damage, 3) permanent disfigurement, 4) fracture or dislocation of bones or joints, 5) neurological, physical or sensory limitation post discharge, 6) specialized medical attention or surgical intervention, 7) transfer • Wrong surgery (patient, site, procedure) • Required unanticipated surgical repair • Removal of unplanned foreign objects post op

  19. Florida Board of MedicineMost Misdiagnosed Conditions • 1) Wrong-site/patient surgery • 2) Cancer • 3) Cardiac • 4) Timely diagnosis of surgical complications • 5) Failing to diagnose pre-existing conditions prior to prescribing contraindicated medications

  20. JCAHO Sentinel Events • Sentinel event not synonymous with medical error • Defined as: An unexpected occurrence involving death or serious physical or psychological injury or risk thereof. Serious injury includes loss of limb or function • Accredited institutions must identify and respond to all sentinel events, including a root cause analysis • Reporting to JCAHO voluntary

  21. Sentinel Event Statistics • Published on JCAHO website • From 1/95 to 12/07 4,817 reports • Mostly from general hospitals (67%), psych facilities or units (20%), ED (4%), LTC (3%) • Death as outcome (70%) • Most reported event – wrong site surgery (13%)

  22. Error Reduction and Prevention Measures • Collection of error data • Education and setting of national safety goals • Systems process changes • Root cause analysis of errors

  23. Patient Safety Organizations • Patient Safety and Quality Improvement Act of 2005 • Congress creating federal regulations to protect the confidentiality of information collected by patient safety organizations • Proposed rule issued 2/12/08 in Vol. 73, No. 29 Federal Register page 8112 • Proposed rule criticized for limited protections offered

  24. 2008 National Patient Safety Goals • To promote specific improvements in patient safety • JCAHO sets annual goals guided by advisory group of experts in patient safety- systems engineers, health care providers, and technical types • Individualized by facility type – hospital, LTC, etc.

  25. Sample 2008 NPSGs and Recommendations for Hospitals • Improve accuracy of patient identification • Use 2 identifiers • Improve staff communication • Read back verbal orders, create a “do not use” list of abbreviations, measure timeliness of getting critical lab results to the responsible caregiver, standardize approach to “hand off” communications

  26. More Sample Goals • Improve the safety of using medications • Identify and annually update look-alike, sound-alike drugs and implement protections • Label all meds and containers like syringes, medicine cups or basins even on sterile fields • Reduce the likelihood of patient harm associated with anti-coagulant therapy

  27. More Sample Goals • Improve recognition and response to changes in a patient’s condition • The organization selects a suitable method that enables health care staff members to directly request assistance from a specially trained individual when a patient’s condition appears to be worsening

  28. Education with a Bite • Effective October 2008, Medicare will not pay hospitals when they make certain errors nor can the patient be billed for costs associated with errors • Forcing hospitals to pay attention to patient safety due to financial impact • No pays: • UTI or sepsis from catheters, falls, decubiti, retained surgical items, blood incompatibility, mediastinitis post heart surgery, and air embolism, (3 more to be added next year)

  29. Systems Process ChangesStructure, Environment, and People • Simplification • Standardization • Process design includes prompts • Elimination of sound/look-alikes • Environment/product improvements • Training • Teamwork • Communication

  30. Root Cause Analysis • Retrospective error analysis to identify the basic or causal factors that underlie variation in performance • Should focus primarily on system and processes, not on individual performance • JCAHO has specific requirements

  31. Special Population Safety Considerations

  32. Pediatric Safety • What makes sick kids safety hazards? • What makes healthcare delivery hazardous for kids? • How can we make healthcare delivery safer for kids?

  33. Safety for the Chronically Ill • What makes the chronically ill safety hazards? • What makes healthcare delivery hazardous for the chronically ill? • How can we make healthcare delivery safer for our chronically ill?

  34. Cultural Competence and Safety • Language barriers • Social-behavioral differences • Literacy

  35. Multifaceted Teams • Physicians • Nurses • Pharmacy • Respiratory therapy • Physical, occupational and speech therapy • Radiology • Social services • Lab • Dietary • Transportation

  36. Patient Inquiry • OTC medications • Alternative therapies • Allergies/side effects • Knowledge of diagnosis and treatment plan information

  37. Helpful Websites for Patients • JCAHO “Speak Up” program • http://www.jcaho.org/general+public/patient+safety/speak+up/index.htm • AHRQ Patient Safety Directory Page • http://www.ahcpr.gov/qual/errorsix.htm

  38. What’s Necessary? • More information and analysis of errors with evidence backed system and process solutions • More education of health care providers and consumers • Culture change inside health care delivery systems • Changing the culture of blame • Reasons for changing the culture of blame • Legal impediments • Creating the right legal/research environment

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