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Medication errors and patient safety

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... 98,000 deaths due to medical errors ... Medical interventions are, by their nature, high-risk procedures ... medication administration records ... – PowerPoint PPT presentation

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Title: Medication errors and patient safety


1
Medication errors and patient safety
  • Vic Vernenkar, D.O.
  • Department of Surgery
  • St. Barnabas Hospital

2
Quality in Healthcare
  • Begins with ensuring patient safety

3
Patient safety
  • Freedom from injury or illness resulting from the
    processes of healthcare

4
Healthcare errors
  • Top worry of patient!

5
Healthcare errors
  • Failure to diagnose / incorrect diagnosis
  • Failure to utilise or act on diagnostic tests
  • Inappropriate use or outmoded diagnostic tests /
    treatments
  • Failure to monitor or provide follow-up
  • Wrong site surgery, medication errors
  • Transfusion mistakes

6
Healthcare errors
  • Nosocomial infections
  • Patients falls
  • Pressure sores
  • Phlebitis associated with intravenous lines
  • Restraint related strangulation
  • Preventable suicides
  • Failure to provide prophylaxis

7
How big is the problem?
  • USA
  • errors by HCWs affect about 3-4 patients
  • mean of 7 ADEs
  • gt7,000 ADE deaths / year
  • 2 million nosocomial infections / year
  • average ICU patient experiences almost 2 errors
    per day
  • each year, 44,000 - 98,000 deaths due to medical
    errors
  • annual cost of medical errors US29 billion

8
Medication errors
  • Prescribing errors
  • Administration errors
  • includes failure to monitor drug levels and side
    effects of treatment

9
Medication errors
  • Rate of 3.99 per 1000 medication orders (Albany,
    NY, USA)
  • a third had potential to cause adverse events
  • Common factors
  • failure to take account of declining
    renal/hepatic function
  • failure to check for possible allergic responses
  • using wrong drug name or means of administration
  • miscalculation of dosage
  • prescribing an unusual critical frequency of dose

Lesar et al. Factors related to medication
errors. JAMA 1997 277 312-7
10
Why did it happen?
  • Technology e.g. infusion pumps
  • Many care-givers
  • High acuity of illness / injury
  • Environment prone to distraction
  • Time-pressured, need to make quick decisions
  • High volume, unpredictable patient load

11
Key reasons
  • Patients are more at risk than non-patients
  • Medical interventions are, by their nature,
    high-risk procedures - small error margins
  • Medicine remains an inexact, hands-on endeavour

12
Errors are inevitable
.but most are preventable
13
Facts
  • Often it is the best people who make the worst
    errors
  • About 90 of errors are not culpable
  • But some people knowingly adopt behaviors more
    likely to produce error - substance abuse, long
    working hours

14
Organisational accident model
James T Reason
15
  • Process review and change

16
Whose job is it? - Risk Manager?
17
Lessons from past
  • Problems often formally recognised when there is
    a major incident
  • Methodologies for organisational analysis not
    well developed
  • Short-term corrective action not well sustained
  • Problems in dealing with aftermath of service
    failure - grievance of victims and their families

18
Cycle of prevention
19
Recommendations
  • Leadership priority
  • Clear organisational commitment to patient safety
    (infrastructure and resources)
  • No-blame culture

20
Culture of safety
  • Integrated pattern of behaviour
  • Underlying philosophy and values
  • Continuos search to minimise hazards and patient
    harm

21
Culture of safety
  • Acknowledges high risk, error prone nature
  • Widespread shared acceptance of responsibility
    for risk reduction
  • Open communication about safety concerns,
    non-punitive environment
  • Reporting of errors and safety concerns

22
Culture of safety
  • Learns from errors
  • Accountability for patient safety
  • Organisational structure, processes, goals and
    rewards aligned with improving patient safety

23
Strategy 1 teams
  • Implement known safe practices
  • Design work so that it is easy to do it right and
    hard to do it wrong
  • Reduce reliance on memory
  • Less steps
  • Constraints
  • Protocols and checklists
  • Clinical Pathways
  • Care process models

24
Teams - lessons from the navy
  • Members monitor each others performance and
    stepped in to to help out. TRUST was an implicit
    part of this.
  • Giving and receiving feedback was norm for all
    team members. Understanding each others role is
    important part.
  • Communication was made real senders checked
    their messages were received as intended.

25
Teamwork and team leadership
  • Good teams do not develop on their own
  • organisational culture of welcoming openness and
    monitoring changes that result
  • Good team leadership is essential
  • development is vital across organisation

26
Hospital team activities
  • Improving information access
  • hospital teams redesigned medication
    administration records
  • Standardising and simplifying medication
    procedures
  • teams worked on high risk and high
    error-potential drugs
  • Restricting physical access to potentially lethal
    drugs
  • chemotherapy drugs, concentrated KCl, NaCl
  • Educating clinical staff about medications
  • to assess knowledge deficiencies, drug knowledge,
    awareness for potential for error

Silver et al. Reducing medication errors in
hospitals a peer review organisation collaboratio
n. J Qual Improvement 2000 26 332-40
27
Strategy 2 education
  • Recognise effect of fatigue on performance
  • Education and training for safety
  • Teamwork
  • Reduce known sources of confusion
  • Awareness
  • Education

28
Training and supervision
  • Training in organisational aspects of care
  • medical training focuses on diagnosis and
    management of individuals
  • Training in skills of risk management
  • understanding of inevitability of human error
  • factors associated with errors, mistakes and near
    misses
  • appropriate checking behaviour, safe handover
  • team work

29
Strategy 3 accountability
  • Acknowledge error
  • Apologise
  • Provide remedial care
  • Conduct root cause analysis
  • Fix system or process problems
  • Risk management system
  • Sentinel event team

30
Clinical incident reporting system
  • Success depends on change in culture
  • staff must be convinced of importance of patient
    safety
  • board has to agree on no-blame culture
  • systematic and strategic approach to risk
    management
  • reporting system must produce reports that are
    timely and informative

31
Main Incident Page Reporting Person
32
Risk Management System (RMS)
Fall Report
Fall Report
Fall Report
Fall Report
Sharp Report
Sharp Report
Sharp Report
Sharp Report
CEO/CMB
Reporting Nurse
Nurse Manager
Follow-up Doctor
Assist. Director Nursing
Sharp Report
CMB / Administrator
Sharp Report
Injured Staff
Supervisor / Manager
Sharp Report
Sharp Report
Sharp Report
Doctor Management
Dept Of Quality Management
Reporting Doctor
Fall Report
Head of Department/ Division Chairman
Medication Error Report
Medication Error Report
Medication Error Report
Infection Control (Sharp only)
Pharmacy Manager
Reporting Person
33
Risk Management System
34
Sentinel Event Team
  • CEO
  • CMB
  • Administrator, Nursing
  • Director, QM
  • Administrator, Medical Board

35
Sentinel Event Team
  • Incident reporting, complaints
  • Category I
  • SET discussion
  • Appoints team to investigate

36
Root cause analysis
  • Reviewing the process
  • What happen?
  • How did it happen?
  • Why did it happen?
  • What can we do differently?

37
MOH requirement
  • Report within 7 days of knowing
  • Submit full report within 60 days
  • De-identify
  • Objective how can we improve
  • what happen, how did it happen, why did it
    happen, can we do differently?

38
Impact
As evidence in support of the value of the
changes made to our processes, we observed no
further fatal ADEs.. John Rex et al.
Systematic root cause analysis of adverse drug
events in a tertiary referral hospital. J Qual
Improvement 2000 26 563-75
39
  • Key findings in IOM report
  • Errors occur because of system failures
  • Preventing errors means

designing safer systems of care
To Err is Human.
Institute of Medicine, 2000.
Committee on Quality of Health Care in America.
40
IOM report
  • Avoid reliance on memory
  • Use constraints or forcing functions
  • Avoid reliance on vigilance
  • Simplify key processes
  • Standardise work processes

41
Institutional practice
  • Clinical risk management system
  • Plan
  • Process
  • People
  • Culture
  • LEADERS
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