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Patient Safety

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Title: Patient Safety


1
Patient Safety Information Technology
  • Saeid Eslami
  • s.eslami_at_amc.uva.nl

2
Errors and ADEs are costly
  • Adverse Events in USA Hospitals
  • 80,000 people hospitalised/year
  • 7,000 deaths/year.
  • 50 of these errors definitely or possibly
    preventable
  • 22 billion, costs of preventable adverse events
  • (1999 USA Institute of Medicine Report)

3
Errors and ADEs are costly
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  • At least 1.5 million preventable ADEs occur each
    year in the US
  • Hospital 380,000-450,000.
  • Ambulatory Care 530,000
  • Long-term care 800,000
  • Cost of ADE
  • Non-preventable ADE 2,595
  • Preventable ADE 4,685
  • Bates DW et al . JAMA. 1997

4
Errors and ADEs are costly
  • In Holland (2005)
  • Each year 10,000 people receive wrong medication
    and more than 3000 death each year because of
    errors.
  • In Australia
  • Medical error results in as many as 18 000
    unnecessary deaths, and more than 50 000 patients
    become disabled each year.
  • AU 5 Billion (AUS)

5
Medication Errors
  • nearly 1 of every 5 doses in the typical hospital
    and skilled nursing facility.
  • The percentage of errors rated potentially
    harmful was 7, or more than 40 per day in a
    typical 300-patient facility.
  • The problem of defective medication
    administrations systems, although varied, is
    widespread.
  • Medication Errors Observed in 35 Health Care
    Facilities Kenneth N. Barker, PhD Elizabeth A.
    Flynn, PhD, et al. (REPRINTED) ARCH INTERN
    MED/VOL 162, SEP 9, 2002 2002 American Medical
    Association

6
Adverse Events -International information
  • AEs Preventable
  • 7.5 36
  • 2.9 --
  • 16.6 51
  • 10.6 --
  • 3.7 --
  • 10.8 48
  • 12.9 37
  • Baker et al, Canada 2000
  • Thomas et al, Utah Colorado 1992
  • Wilson et al, Australia, 1995
  • Thomas et al, 2000, reworked 1995 Australian data
  • Brennan et al, Leape et al, New York 1984
  • Vincent et al, London 1999,2000
  • Davis et al, New Zealand 1998

Slight to modest evidence of healthcare
management causation 2 out of 6 scale, other
papers management causation more certain- 4 out
of 6 scale
7
Estimated Deaths Due to Medical Error
Source The Philadelphia Inquirer
8
The(US) National Burden of Systemic Errors in the
Health Care
More than 3 fully occupied Jumbo jets of the
Health Care Industry drop out of the sky every
day !
(Adapted from Leape
the Patient Safety Guru of USA)
US Healthcare
In 2001 there were 4.3 million ambulatory visits
for treating Adverse Drug Events Zhan et al 2005
And then there are other adverse Events!!
9
How Hazardous Is Health Care?(Modified from
Leape)
Ultra-Safe (lt1/100K)
Dangerous (gt1/1000)
Regulated
HealthCare
Driving
Total lives lost per year
Scheduled Airlines
Chemical Manufacturing Chartered Flights
European Railroads
Mountain Climbing
Bungee Jumping
Nuclear Power
Numbers of encounter for each fatality
10
Definitions
Patient safety defined as freedom from
accidental injury due to medical
care.. Institute of Medicine. To Err is Human.
Building a safer Health System, Washington,
National Academy Press 1999
An adverse events harm or injury caused by the
management of a patients disease or condition by
health care professionals rather than by the
underlying disease or condition itself The
World Health Profession Alliance
11
Definitions
  • Sentinel Event
  • An unexpected occurrence involving a death or
    serious physical or psychological injury or risk
    thereof. Serious injury specifically includes
    loss of limb or function.
  • Preventable Adverse Event
  • Could/should not have happened (Error)
  • Non-Preventable Adverse Event
  • Could not have been predicted or foreseen
  • Potential Adverse Event
  • Near miss or close call, could have resulted
    in an accident, injury or illness, but did not,
    either by chance or through timely intervention
  • Error
  • the failure of a planned action to be completed
    as intended
  • the use of a wrong plan to achieve an aim.

12
Errors Types (another classification)
Overuse in 2001 top 50 medical and surgical
procedures numbered 42 million. 7.5 million of
these were unnecessary surgical procedures
causing about 40,000 deaths. Underuse Much
greater problem than Overuse. Patients failed to
receive recommended care about 46 of the time.
e.g. hypertension receives 65 of recommended
care. Misuse About 11 of the time patients
receive care not recommended leading to harm
G and R Singh
13
Medical Errors Adverse Events
Non-preventable
Medical Errors
AE
Near Miss
Preventable AE
Serious Medical Errors
14

Patients Encounter with Health Care System
No error occurs
IF
IF
Beneficial outcome may occur
Unavoidable adverse event occurs
OUTCOME
Advances in medical knowledge required to prevent
recurrence
Opportunities for system redesign and improvement
commonly go unnoticed
ACTION RQD
A, R G Singh 2002
15

Patients Encounter with Health Care System
Error occurs
IF
IF
Consequential
Preventable adverse event occurs
OUTCOME
System redesign and improvement required to
prevent recurrence
ACTION RQD
A, R G Singh 2002
16

Patients Encounter with Health Care System
Error occurs
IF
IF
Inconsequential on its own
Beneficial outcome may occur
OUTCOME
Opportunities for system redesign and improvement
commonly go unnoticed
ACTION RQD
A, R G Singh 2002
17

Patients Encounter with Health Care System
Error occurs
IF
IF
Inconsequential on its own
IF
Undetected (may cause cascade of errors)
IF
Preventable adverse event occurs
OUTCOME
System redesign and improvement required to
prevent recurrence
ACTION RQD
A, R G Singh 2002
18

Patients Encounter with Health Care System
No error occurs
Error occurs
IF
IF
Inconsequential on its own
Consequential
IF
Undetected (may cause cascade of errors)
Detected and corrected
IF
IF
Beneficial outcome may occur
Preventable adverse event occurs
Unavoidable adverse event occurs
OUTCOME
OUTCOME
System redesign and improvement required to
prevent recurrence
Advances in medical knowledge required to prevent
recurrence
Opportunities for system redesign and improvement
commonly go unnoticed
ACTION RQD
ACTION RQD
A, R G Singh 2002
19
Isordil or Plendil?
20
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21
Other Example
  • Glucose
  • Oxygen/CO2

What shall manager do? How can we prevent them?
22
More Common than We Thought
  • Underestimated by a factor of 20 or greater
  • Reports in health care would presumably number
    in the millions if adverse events, no harm
    events, and near misses were captured.
  • Agency for Healthcare Research and Quality,
    Making Health Care Safer A Critical Analysis of
    Patient Safety, July 2001 Donald Holmquest, MD,
    PhD, JD
  • Chief Technology Offices, eMedical Research, Inc.
    3000 medical fatal errors for 1,000,000 people

23
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24
Richard Smith
25
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26
Knowing is not enough we must apply. Willing is
not enough we must do. Wolfgang von Goethe
27
How to think of error?
  • An individual failing
  • It will not solve the problem--it will probably
    in fact make it worse because it fails to address
    the problem
  • Doctors will hide errors
  • May destroy many doctors inadvertently (the
    second victim)
  • A systems failure
  • This is the starting point for redesigning the
    system and reducing error

28
James Reasons bottom line
  • Fallibility is part of the human condition
  • We cant change the human condition
  • We can change the conditions under which people
    work

29
Good Outcomes, Good Systems
  • Historically, mistakes or poor outcomes have
    been blamed on dumb doctor, or dumb nurse.
    The solution was the ABP reaction Accuse,
    Blame and Punish.
  • But inefficiencies and errors mostly can be
    traced not to one error, but a cascade of poor or
    poorly executed procedures, policies,
    technologies and training. A good system will
    provide a good outcome a poorly designed one
    will produce a poor one.
  • We need to design health care systems that put
    safety first (First, do no harm)
  • Hopkins Medical News, Edward D. Miller, M.D.,
    Fall 2002, Page 56

30
A System Problem
adverse events are generally not the result of
one thing that went wrong. They result from the
combination of a series of latent errors that are
built into the system. Paul M. Schyve, MD,
Vice President, JCAHO In Reducing Medical
Errors, Improving Patient Safety Taking the Next
Step, HealthLeaders Roundtable, June 2001.
31
Swiss cheese model
32
Be careful!
33
Theory of Constraints
  • Any improvement is a change
  • not every change is an improvement
  • but we cannot improve something unless we change
    it
  • Goldratt (1990)

34
Any improvement is a change
  • any change is a perceived threat to security
  • there will always be someone who will look at the
    suggested change as a threat
  • any threat to security gives rise to emotional
    resistance
  • you can rarely overcome emotional resistance with
    logic alone
  • emotional resistance can only be overcome by a
    stronger emotion
  • Goldratt (1990)

35
Anyone who thinks you can overcome emotional
resistance with logic was probably never married
36
  • Panic
  • Zone
  • people
  • close up
  • they
  • freeze
  • they dont
  • learn
  • Comfort Zone
  • people stay here
  • they dont learn
  • they dont change

37
Panic Zone
Comfort Zone
  • uncertainty
  • learning

38
It is important to be aware of
Tell me and I will forget Show me and I may
remember Involve me and I will understand
In comparison with See one Do one Teach one
39

Involve the nurses
40
Discipline of Improvement
4 equally important parts of improvement
Vision Every single person is capable, enabled
and encouraged to work with others to improve
their part of the service Discipline of
improvement in health and social care (Penny
2003)
41
No relationship between cost and mortality in UK
Source Pursuing Perfection programme
42
  • Glucose
  • Oxygen/CO2

What shall manager do? How can we prevent them?
43
Safety Principles
  • Error prevention
  • Making errors visible
  • Mitigation of harm from errors

44
  • No problem can be solved within the same
    consciousness which caused it.
  • Albert Einstein
  • Since modern information tools can do things
    that the unaided human mind cannot do, when we
    use such tools we may see a picture of medicine
    we have not seen before.
  • Larry Weed
  • there are enormous voltage drops along the
    transmission line for medical knowledge.
  • Lawrence Weed (1997)

45
Safety in Flying
  • 1903 First Powered Flight
  • 1908 First Pilot dies
  • 1910 First mid-air collision
  • 1918 31 of first 40 US Air Mail pilots die in
    crashes
  • 1994 4 crashes/10,000,000 takeoffs

46
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47
Flight vs. Healthcare
  • Machine vs. Human (Flight)
  • Human vs. Human (Healthcare)

48
Information Technology
A growing body of evidence supports the
conclusion that various types of IT applications
lead to improvements in safety Nonetheless, IT
has barely touched patient care. Source IOM,
Crossing The Quality Chasm, p. 187.
49
Information Technology to Improve Patient Safety
  • Electronic medical records (EMR)
  • Electronic orders and prescribing Computerized
    Physician Order Entry (CPOE)
  • Electronic decision-support tools
  • Handheld devices (PDAs)
  • The electronic office

50
Technology has Become a Preferred Solution by
Many Groups
  • IOM reports
  • Leapfrog
  • ISMP
  • Media
  • Legislators

51
?
?
Order ____________________________________
52
3
  • Dose calculation
  • single dose
  • dosing intervall
  • divisibility

1
2
  • Watchdog
  • renal failure?
  • special dose requirements?
  • Contraindications?

53
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54
Generation I
Create a clinical data repository consolidation
key clinical data From this database,
information can be located efficiently and
reliably Generation I 15 reduction in
preventable errors
55
Generation II
Implementation of basic clinical decision
support systems (CDSS) - a key for eliminating
errors GI (15) GII (25) 40 reduction in
preventable errors
56
  • Reducing Haphazard Decisions

57
for example sedation
  • Midazolam (Dormicum)
  • sedative before interventions
  • (e.g. dental or other surgery, endoscopy)
  • sedation in respirator therapy
  • emergency treatment of epileptic fits
  • (e.g. status epilepticus)

58
Midazolam clearance
Adults
Children
Clin Pharmacokinet 983537
59
Midazolam distribution
Children
Adults
Clin Pharmacokinet 983537
60
Midazolam dosing according to weight
Children
Adults
61
Renal failure risk without dose adjustment
Irreversible cerebellar damage
Coma, epileptic fits
Confusion
Arrhythmia, K
Grandmal
AV-Block
62
Drug-Drug Interaction
5 drugs
10 drugs
63
Generation III
Combining CDSS across the continuum of care (in
and out patients) Use of controlled medical
vocabulary to normalize medical concepts CPOE
(to better manage ordering) Work flow
improvements Combining work flow change and
CDSS This 3rd generation has the basic
infrastructure to measure or asses incidence of
potential errors and measure effectiveness of
interventions GI (15) GII (25) GIII (30)
70 preventable error. IOM goal of at least a
50 reduction of preventable medical errors
64
Errors resulting in ADEs Harvard Study
Bates DW et al. Incidence of adverse drug events
and potential adverse drug events. JAMA
199527429-34.
65
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66
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67
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68
Generation IV
More sophisticated CDSS Tailored care to the
individual patient Disease management
tracking Protocols (Care management,
Clinical) GI (15) GII (25) GIII (30)
GIV (20) 90 preventable error.
69
Generation IV
  • After the next decade 2010
  • Highly sophisticated CDSS
  • True evidence-based medicine
  • Outcomes tracking of each episode of care
  • Links to NLM and new medical research results
    from the medical literature
  • Interfaces to mobile personal monitoring devices
  • Personalized accessible patient record
    information anywhere

70
PEDIATRICS Vol. 116 No. 5 November 2005 The
Introduction of Computerized Physician Order
Entry and Change Management in a Tertiary
Pediatric Hospital Jeffrey S. Upperman MD
Patricia Staley BA Kerri Friend BA Jocelyn
Benes RN Jacque Dailey RN William Neches MD and
Eugene S. Wiener MD From the Departments of
Surgery, Quality and Care Management, and
Cardiology, Childrens Hospital of Pittsburgh,
Pittsburgh, Pennsylvania Conclusion. CPOE is an
invaluable resource for supporting patient safety
in health care settings.
PEDIATRICS Vol. 116 No. 6 December 2005
Unexpected Increased Mortality After
Implementation of a Commercially Sold
Computerized Physician Order Entry System Yong
Y. Han, MD Joseph A. Carcillo, MD Shekhar T.
Venkataraman, MD Robert S.B. Clark, MD R.
Scott Watson, MD, MPH Trung C. Nguyen, MD Hülya
Bayir, MD and Richard A. Orr, MD From the
Departments of Critical Care Medicine and
Pediatrics and Clinical Research, Investigation
and Systems Modeling in Acute Illness (CRISMA)
Laboratory, University of Pittsburgh School of
Medicine, Childrens Hospital of Pittsburgh,
Pittsburgh, Pennsylvania Conclusion. We have
observed an unexpected increase in mortality
coincident with CPOE implementation.
71
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72
Technology Adoption, Change!
No. of years for 30 of Americans to own
technology Telephone 40 years Television 17
years PC 13 years Internet 7 years D.Z.
Sand, HIMSS presentation 2002, Cambridge
Technology Partners
73
Thermometers
Physicians had always avoided applying
mathematics to the study of the body or disease.
In the 1820s, 200 years after the discovery of
thermometers, French clinicians began using
them. The Great Influenza, John M . Barry p25
74
Main Barriers
  • Physicians were taught to be independent and
    have been resistant to guidelines and systems
  • Physicians view teamwork as golf teams not
    volleyball teams
  • Disruptive behavior has been tolerated and in
    some respects rewarded among physicians

75
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????? ? ????? ???? ?? ????!
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