Patient Safety 2013

1. Patient Safety2013 Prevention of Medical Errors

2. Why are we here? • Concern over incidence of Medical Errors • IOM Landmark Report (1999) • To Err is Human: Building a Safer Healthcare System • Statistics • 44,000 – 98,000 Hospital deaths due to medical error

3. Impact of IOM Report • Sparked a National Effort to: • change the culture of healthcare • change the systems of healthcare • Culture change development: • Emphasis on compliance with standards • Good safety performance as a valued organizational goal • Emphasis on continuous improvement

4. Impact of IOM Report • System Changes: • Move from Blame to Safety • Shift from character and people related flaws to system and process flaws • Discard the need to blame • Embrace the blameless exploration of systems, processes and mechanisms

5. Why are we here? • To commit to paying greater attention to the problem • We make a difference one at a time • To evaluate current and new approaches • To build better systems to reduce the incidence of error

6. Why are we here? • 2001 FL Legislative response • FS 456.013 • Mandates 2 hour course for ALL health care providers as part of licensure and renewal process • Course shall include the study of: • root-cause analysis • error reduction • error prevention • patient safety

7. Why are we here? • FL BON Requirement • 64B9-5.011 • Continuing Education on Prevention of Medical Errors

8. FL BON Requirement • Subject Areas: • Factors that impact the occurrence of medical errors • Recognizing error-prone situations • Processes to improve patient outcomes • Responsibilities for reporting • Safety needs of special populations • Public education

9. Definitions • Error (IOM): • The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim • Adverse Event: • Injury caused by medical management rather than underlying disease condition

10. Definitions • Medical Error • Preventable adverse events with our current state of medical knowledge • Not defined as intentional act of wrongdoing • Not all rise to level of medical malpractice or negligence

11. Reporting Requirements • Florida Law requires all licensed facilities to: • Have Internal Risk Management and incident reporting system • Report Serious Adverse Events to: • AHCA Agency for Health Care Administration • See Sentinel Event Reported by year for guidelines

12. Joint Commission • National organization • Mission to improve the quality of care in healthcare institutions • Provides Accredited status to healthcare facilities

13. Joint Commission • Requires: • Process in place to recognize sentinel events • Credible root cause analysis (RCA) • Focus on systems not individuals • Risk reduction strategies • Internal corrective action plan • Measure effectiveness of process • System improvements to reduce risk

14. Root Cause Analysis • Goal-directed, systematic process • uncovers basic factors that contribute to medical error • Focuses primarily on systems and processes and not individuals • Product of root cause analysis is an action plan to reduce risk of similar future events

15. Root Cause Analysis • Gather facts • Assemble team • Determine sequence of events • Identify causal factors • Select root causes • Take corrective action and follow-up plan

16. Joint Commission Sentinel Event Statistics • Joint Commission Website • Go to Topics, Sentinel Event, Statistics • View Sentinel Event • Summary • General Information – pg. 7 • Root Causes – data unavailable – look at last year • Trends Reported by Year

17. Sentinel Events by Type Joint Commission Data 2004 - 2010 • Top 6 • Wrong Pt., Wrong Site, Wrong Procedure • Delay In Treatment • Op/Post-Op Complications • Unintended Retention of Foreign Body • Suicide • Fall

18. Sentinel Events by Setting Joint Commission Data 2004 - 2010 • Hospital (63.9%) • Psychiatric Hospital (11.4%) • Emergency Dept. (6.8%) • Psych unit in general hosp. (5.6%) • Behavioral health facility (3.9%) • Ambulatory Care (3.9%)

19. Medication ErrorsPrevention • Joint Commission abbreviations on the • DO NOT USE list: • What is the leading root cause of medication Errors?? • Answer Poor communication

20. Joint Commission Do Not Use List • U for Unit – write unit • IU for International Unit – write international unit • QD, QOD – Write daily or every other day • Trailing zero (X.0 mg.) – write (X mg.) • Lack of leading zero (.X mg) - write (0.X mg) • MS, MSO4, MgSO4 - write morphine sulfate, magnesium sulfate

21. Items Reviewed annually by Joint Commission • The symbols “>” and “<”All abbreviations for drug namesApothecary unitsThe symbol “@”The abbreviation “cc”The abbreviation “μg”

22. ISMP: Tall Man Letters • Table 1. FDA Approved List of Established Drug Names with Tall Man Letters • acetoHEXAMIDE ­acetaZOLAMIDE • hydrALAZINE – hydrOXYzine • buPROPion ­busPIRone • medroxyPROGESTERone methylPREDNISolone methylTESTOSTERone • chlorproMAZINE – chlorproPAMIDE • clomiPHENE – clomiPRAMINE • cycloSPORINE – cycloSERINE • niCARdipine – NIFEdipine • DAUNOrubicin – DOXOrubicin • predniSONE – prednisoLONE • dimenhyDRINATE – diphenhydrAMINE • sulfADIAZINE – sulfiSOXAZOLE • DOBUTamine – DOPamine • TOLAZamide – TOLBUTamide • glipiZIDE – glyBURIDE • vinBLAStine – vinCRIStine

23. ISMP • Links to FDA Safety Alerts and Medication Safety Videos • http://www.ismp.org • www.fda.gov/psn And Much, Much More – A Great Resource!

24. Collaborative Learning Activity • Work in small groups of 5 – 6 • Discuss specifically what you can do in your life or practice setting to reduce medical errors • Decide on 3 error reduction strategies to present to the group.

25. Creating a Culture of Safety • Understand human factors and system flaws • Make safety everyone’s responsibility • Report errors or near misses to decrease future error • Actively seek improvement to process

26. Creating a Culture of Safety • 6 major categories of negligence: • Failure to follow standard of care • Failure to use equipment in proper, responsible manner • Failure to communicate • Failure to document properly • Failure to accurately assess and monitor • Failure to act as an advocate for the patient