Introduction to Patient Safety

1. Introduction to Patient Safety Nazanin Meshkat MD, FRCP, MHSc

5. Lessons from Chernobyl • Operators continued a planned test despite multiple indicators that things were going wrong • System errors • A shut down system that was too slow • An over reliance on operators for system operation • A lack of communication • Poor planning

6. Safety Critical Industries • Nuclear plants • Aviation • Healthcare

7. Objectives • What is an “unsafe act” and error • Understand why errors occur • Human factors engineering • To understand the role of teamwork and communication in patient safety

8. Patient Safety • World Health Organization definition = "freedom…from unnecessary harm or potential harm associated with healthcare”

9. “To Err Is Human” • Institute of Medicine 1999 • 44,000 and 98,000 people die each year in US hospitals due to medical errors • More than motor vehicle accident deaths in US

10. Likely Under-Reported • Errors are not always recognized when they occur • Fear of punishment • Reporting systems can be cumbersome.

11. So what? • Cost to… • Individual • Family • Health care providers • Healthcare system

12. Centers for Medicare and Medicaid Services (CMS), more than one million patient safety incidents occurred to hospitalized Medicare patients in the US over the years 2002 to 2004, causing more than 250,000 deaths and costing $9.3 billion

13. Why do errors occur?

14. Pharmacy Wards Lab Limited Resources Nurse Anesthetist Variable Pt Volumes Drugs ER Doctor Resident Rapid Decisions New Research, poor knowledge translation Patient High acuity Many Distractions and interruptions Nurse Medical Student Handoffs Variability in practice Intern Radiology Department Consultants Lab

15. SYSTEM Information flow

16. Transitions or “handoffs” • Risky time • Great deal of information to communicate • Short amount of time • Human factors - interruptions, tired • Information is LOST, FORGOTTEN, MISCOMMUNICATED

17. “Dynamic non-event” • To make "nothing bad happen" requires a lot of good things to be done right.

18. We all do unsafe things • After a night shift, I got into my car to drive home, and while making a right turn, I rear-ended another car

19. Unsafe Acts • Errors • Violations

20. Errors • Errors classified into two types of failures • An action goes as intended but it’s the wrong one = Mistake • An action does not go as intended = Error of Execution • Slip - Action Based • Lapse - Memory Based (a lapse in memory)

21. Violations • “A deliberate deviation from an operating procedure, standard or rule” • “Drift” a slow, incremental move away from safe actions

22. How do we make decisions… • Automatic cognition • Active problem solving

23. Automatic Cognition • Concept of heuristics - cognitive shortcuts that allow for rapid, often unconscious decision making • You get up in the morning, brush your teeth, shower…

24. Are these lines straight? Optillusions.com

25. Automatic Cognition • Unfortunately, heuristics are also associated with cognitive biases that can be strong, but incorrect. • Errors in Automatic Cognition are Caused by Errors of Execution (slips and lapses)

26. Example of Heuristics • DO----MINE - dopamine or dobutamine • HY----ZINE - hydralazine or hydroxyzine

27. Problem Solving • Problem-solving is slow, conscious, sequential

28. Problem Solving Errors • Affected by “habits of thinking” • Cognitive biases • Memory bias • Overconfidence • Confirmation bias

29. Both Automatic Cognition and Active Problem Solving Affected by… • Internal Factors or endogenous causes • Psychological states (anger, fear, boredom, anxiety) • Physiological states (fatigue, illness) • External Factors or exogenous causes • Environmental factors (noise, heat, light), long work schedules, inadequate training, interruptions and distractions

30. Both Automatic Cognition and Active Problem Solving Affected by… • External Factors or exogenous causes • Environmental factors (noise, heat, light) • Long work schedules • Inadequate training • Interruptions and distractions

31. Internal Factors Peak Performance Anxiety Boredom Stress Levels

32. Internal Factors • Impact performance and personality negatively • Reduce decision-making ability • Prolong response times • Increase lapses in attention • Affect short term memory • Lessen ability to multitask • Increase irritability, moodiness and depression • Decrease ability to communicate

33. Internal Factors • After one night of missed sleep - performance can decrease by 25% • After 17 hours of being awake, the cognitive performance among test subjects equivalent to that of someone who was drunk • Would you ever consider going to work drunk? Not likely; but you probably go to work tired all the time.

34. Latent Errors vs. Active Errors • Latent errors are existing defects in the design and organization of processes and systems that can lead to failures and errors • often unrecognized or just become accepted aspects of the work • Lead to active errors, whose effects are felt immediately

36. Latent Errors vs. Active Errors • While the person on the front line - the doctor, nurse, or pharmacist - might be the proximal cause of the active error, the real root causes of the error is often present within the system for a long time, as accidents waiting to happen!

37. Latent Errors vs. Active Errors • The process of “Normalization” • Acceptance of unacceptable processes

38. How to Prevent Errors

39. What does not work… • ”Blame and shame” • Countermeasures that have become the norm in medicine include • Creating a sense of fear • Disciplinary measures • Threats of litigation • Retraining (using outdated and ineffective training methods) • Naming, blaming, and shaming.

40. What works… • Instead of telling people to be more careful, you have to change systems • Can redesign systems using “human factors principles”

41. Human Factors Engineering • Human factors is the study of “the interrelationship between humans, the tools and equipment they use in the workplace, and the environment in which they work.” • How to design processes that make it easy for people to do things right • …and hard to do things wrong.

42. How do you do that? • Enhance mental and physiological states • Reduce or mitigate fatigue, stress, dehydration, hunger, boredom, guilt, feeling undervalued, low moral, anxiety

43. How do you do that? • Enhance decision making AND execution through…Environment Design

44. System Redesign • Change Systems - Processes, procedures, communication, equipment, organizational culture

45. System Redesign • Change Systems - Processes, procedures, communication, equipment, organizational culture • Simplify • Standardize • Use forcing functions and constraints • Avoid reliance on memory • Use redundancies • Automate • Promote effective team functioning

46. Simplify • My niece and nephew use their dad’s iPhone all the time! • Because it is so simple to use!!

47. Simplify • Make tasks easy to do • The simpler it is, the less chances an error will be made • The more complex - users may “work around” it (e.g. skips steps)

48. Simplify • Make sure that an item’s purpose is easily understood by the user

49. Eliminate Variation Confusion Complexity Enhance Uniformity Predictability Consistency Standardize Examples - Protocols, Pre-Printed Medication Order Forms, Clinical Care Pathways

50. Constraint makes it difficult to complete a task (when indeed that task should not be completed) E.g Do not keep high dose Potassium Chloride in the medication cabinet to avoid accidental administration to a patient! Use Forcing Functions and Constraints