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Patient Safety 101

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Patient Safety 101 North American Spine Society Patient Safety Basic tenet since Hippocrates first do harm Modern medical advances provide sophisticated ... – PowerPoint PPT presentation

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Title: Patient Safety 101


1
Patient Safety 101
  • North American Spine Society

2
Patient Safety
  • Basic tenet since Hippocrates first do harm
  • Modern medical advances provide sophisticated,
    effective treatments
  • Also are complex, multifaceted with potential for
    errors in judgment, technical misadventure
    system failure

3
Types of Errors
  • Medication (harmless-harmful-lethal)
  • Wrong-site/procedure/patient surgery
  • Miscommunication
  • Transfusion events
  • MRI safety
  • Ineffective clinical alarms

4
How It Started IOM Report
  • To Err is Human-Much publicized Institute of
    Medicine Report-1999
  • At least 44,000 and possibly as high as
    98,000 die in US annually due to medical
    errors
  • 8th leading cause of death in US
  • Perspective
  • Car accidents
  • 43,458
  • Breast Cancer
  • 42,297
  • AIDS
  • 16,516

5
Criticisms of the Report
  • Origin of numbers-National figures for deaths
    extrapolated from only 2 studies
  • Retrospective nature of reviews
  • Suggestion that deaths due to medical errors were
    exaggerated

6
Impact of the Report
  • Major media splash
  • Cries of shock horror from the public, Capitol
    Hill
  • Led to call for reporting systems
  • AHRQ budget increased by 20 million

7
Impact
  • Focused national attention on patient safety and
    heightened awareness of public, health care
    providers, professional societies, hospitals,
    government.

8
Valid Issues of IOM
  • We know medical errors do occur
  • Example-wrong-site surgery. Since 1995, 232
    incidents reported to JCAHO. Probably
    underreported.
  • Highlighted issues of reporting, analysis and
    error reduction.

9
Parallels to Aviation Safety
  • Pilot
  • Co-pilot
  • Crew resource management
  • Doctor
  • Allied health
  • Medical teams

Standardization Accident Investigation Confidenti
al Incident Reporting
10
Medical Error Reporting
  • IOM recommended mandatory reporting
  • Fear of litigation a significant impediment to
    meaningful reporting

11
NASS Position
  • NASS believes nonpunitive, confidential reporting
    is an important preventive measure. The goal of
    nonpunitive, confidential reporting is to
    identify errors, including near misses for
    correction prevention
  • NOT PUNISHMENT OR LIABILITY

12
Six Sigma QualityBorrowing from Industry
  • Coined by Motorola to set tolerance limits in
    manufacturing
  • Six sigma qualityerror limit set 6 standard
    deviations above the mean on a normal
    distribution curve.
  • High quality standard gt3.4 defects per million
    opportunities. ? sigma more defects. ? sigma
    fewer defects.

13
Six Sigma Examples
  • Airline Operation
  • 5 sigma for fatalities230 deaths per million
    opportunities
  • 4 sigma for baggage handling 6,210 lost bags per
    million opportunities
  • Health Care
  • Anesthesia death rate between 25-50 per million
    opportunities in 70s 80s
  • After clinical guideline adoption, rate is 5.4
    deaths per million opportunities. Close to 6
    sigma quality.

14
Medical Errors as Systems Problems
  • Concept
  • System failuresnot individual human failures
    are to blame. Systems can be designed to back up
    human error (the sometimes imperfect human
    memory).

15
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16
Name, Shame Blame
  • Naming the error, shaming blaming individuals
    has not reduced errors. Key to improvement is a
    learning health care system of 8 components.

17
Learning Health Care System
  • Informatics for information
  • Guidelines as learning tools
  • Learning from opinion leaders
  • Learning from the patients
  • Decision support systems
  • Team learning
  • Learning organizations
  • Just in time and point of delivery care

18
What to Do?
  • IOM Recommendation
  • Professional societies should make a visible
    commitment to patient safety by establishing a
    permanent committee dedicated to safety
    improvement and promoting a culture of safety

19
What Your Organization Can Do
  • Patient Education
  • Medical Professional Education (journal articles,
    publications, CME)
  • Research adverse events their causes in your
    specialty
  • Make patient safety a research funding and
    advocacy priority
  • Join with related organizations in safety efforts

20
For more information, contact
  • North American Spine Society
  • (815) 675-0021
  • www.spine.org
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