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ICU safety: to err is human Can we prevent adverse events ?

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ICU safety: to err is human Can we prevent adverse events ? Pr B Guidet, Medical ICU H pital Saint Antoine, Paris, France Acknowledgment : Airbus industrie , Jean ... – PowerPoint PPT presentation

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Title: ICU safety: to err is human Can we prevent adverse events ?


1
ICU safety to err is human Can we prevent
adverse events ?
  • Pr B Guidet, Medical ICU
  • Hôpital Saint Antoine, Paris, France
  • Acknowledgment
  • Airbus industrie , Jean-Jacques Speyer Henri
    Petit
  • SEE Andreas Valentin

2
Incidence and consequences of adverses events
  • Leape L. Error in Medicine. JAMA 1994
  • 4 of all hospital stays
  • mortality rate of14
  • Committee on Quality of Health Care in America,
    Institute of Medicine. 2000.
  • Death related to adverse events
  • 44000 à 98000 patients each year
  • 8th cause of mortality

3
  • Unintended Event
  • An occurrence that harmed or could have harmed a
    patient
  • SEE multicenter, multinational, single day study
    in ICU
  • Reporting by all ICU staff members
  • Voluntarily Anonymously - Confidential

4
Selected Events
SEE STUDY
  • Medication wrong drug, dose, or route
  • Airway unplanned extubation artificial
    airway obstruction cuff leakage
  • Lines, Drains dislodgement Catheters inappropri
    ate opening/disconnection
  • Equipment power supply, oxygen supply,
  • failure ventilator, infusion pump
  • Alarms inappropriate turn off

5
SEE Study participating Countries
220 ICUs in 29 countries 2090 patients
6
Adults
SEE STUDY
  • Patients 1913
  • Sex 61 m / 39 w
  • Age (mean) 62,3 16,3 (18 99 a)
  • NEMS (median) 27 (1838)
  • SOFA (median) 4 (27)
  • Events 584
  • Pts with ? 1 Event 393
  • At least 1 sentinel event 73 of ICUs

7
SEE STUDY
of events in patients (adults)
8
391 affected patients
SEE STUDY
9
SEE STUDY
Events / 100 pt days lower 95 CI upper 95 CI
All 38.8 34.7 42.9
Lines, drains 14.5 12.0 16.9
Medication Prescription Administration 10.5 5.7 4.8 8.6 4.4 3.6 12.4 7.1 6.0
Equipment 9.2 7.4 11.1
Airway 3.3 2.4 4.3
Alarms 1.3 0.6 1.9
10
SEE study
Explanatory power of measured variables
Explanatory power within the final model
11
Time - pattern of events
A look into the nature and causes of human
errors in the ICU Donchin et al, Crit Care 1995
SEE study
12
SEE study
Drug prescription
Drug administration
13

SENTINEL EVENTS EVALUATION (SEE)
  • Information
  • www.hsro-esicm.org
  • Contact
  • andreas.valentin_at_meduniwien.ac.at

14
Adverse events in ICU
  • Frequent and in relation with
  • Severity of the patients
  • Procedures
  • Impact on (Zhan C, Miller MR. Excess length of
    stay, charges, and mortality attributable to
    medical injuries during hospitalization. JAMA,
    2003, 2901868-1874)
  • Morbidity and mortality
  • Finance
  • Iatrogenic pneumothorax 17,312 US
  • DVP and post operative pulmonary emboli 21,709
    US
  • Legal issues
  • Psychology of the team
  • Preventability ?

15
If you hear this I am proud to say that I
have no adverse event in my ICU
16
You should conclude that this is a very
dangerous ICU
  • No documentation of events
  • No evaluation
  • No corrective action
  • May be even no patient in that ICU

17
Medicine and Aviation
  • Safety is primary goal
  • Technological innovation
  • Multiple sources of threat
  • Teamwork is essential

18 March 2000
18
Lessons from Aviation safety
  • 1960 - 1970
  • Old planes
  • Pilots trained during world war II
  • 1970 -1980
  • Check list
  • Simulators
  • Flight analysis
  •  non punishment act 
  • Collective corrective action
  • 1980 - 1990
  • New planes
  • Human factors
  • 1990 2000
  • Instrumentation automation
  • Generalisation of human factors assessment
  • Improvement of logistic
  • Same language
  • communication

40 years
19
Different Approaches in Health Care vs Aviation
  • Health care
  • You will not make a mistake !
  • Individual Responsibility,
  • The Best is not to screw up!
  • Aviation
  • People will make mistakes ! TRAP and MITIGATE
    THEM!
  • Collective Responsibility with SYSTEMS
    APPROACH
  • Systemic Return of Experience
  • Periodic Control of Competencies

20
Cultural safety Paradigms
Traditional paradigm
Ideal paradigm
  • safety a social value
  • human error symptom
  • accidents caused by system flaws
  • incident investigation
  • normal process monitoring
  • safety universal value
  • human error cause
  • accidents caused by individuals
  • accident investigation
  • blame and punishment

21
Aviation and Medicine
  • Constantly changing environments
  • Incomplete information
  • Time urgency
  • Inherent risk

22
Collaborative Rounds
  • Interdisciplinary (everyone present at one time)
  • Patient and family included as part of the care
    team
  • Collaborative Communication
  • Respectful, open environment flat hierarchy

23
Pilots and Doctors Attitudes
Decision making as good in emergencies as
normal Effective pilot/doctor can leave behind
personal problems Performance the same with
inexperienced team Perform effectively
when fatigued

24
Our Biggest Challenge
  • Operators Who Are
  • - Highly Trained
  • - Competent
  • - Experienced,
  • Trying to Do the Right Thing, and
  • Proud of Doing It Well

. . . Yet They Still Commit
Inadvertent Human Errors
25
Human factors
  • Basic training (i.e. CoBaTrice)
  • Periodic control of competency
  • Work as a team
  • Working condition

26
Airbus Training Simulation Realism
27
Work as a team
28
Fatigue as Threat
  • 24 hours of sleep deprivation have performance
    effects comparable to a blood alcohol content of
    0.1 (Drew Dawson Nature, 1997)
  • Aviation flight time limits
  • 8 hours in one day, 30 hours in one week, 100
    hours in one month, 1,000 hours per year
  • U.S. Resident workrules (July 2003)
  • 24 hours in one shift
  • 80 hours in one week
  • No limit for month or year

29
Extended work shifts and the risk of motor
vehicle crashes among interns Barger, NEJM
2005, 352 125
  • 2737 residents
  • Extended work shift
  • 3.9 /month
  • Average duration 32 hours
  • Odd Ratio after an extended work shift
  • Motor vehicle crash 2.3
  • Near-miss 5.9

30
Effect of Reducing Interns' Work Hours on Serious
Medical Errors in Intensive Care Units Landrigan
CP, for the Harvard Work Hours, Health and Safety
Group NEJM 2004, 3511838
  • interns working according to a traditional
    schedule with extended (24 hours or more) work
    shifts every other shift
  • while working according to an intervention
    schedule that eliminated extended work shifts and
    reduced the number of hours worked per week

31
Human Error in Aviation Safety
  • Management of Human Error?
  • Select the right people and Train them properly,
  • Tailor Procedures to operational requirements,
  • Monitor Performance on a continuous basis,
  • Provide Feedback to identify and correct
    problems through improved Design ,
    Selection,Training and Procedures,
  • Create a Safety Culture in the Work environment

32
Structure - equipment
33
Evolution from the early days...
34
To todays Human Machine Interfaces...
35
(No Transcript)
36
Bar Coding for Patient Safety NEJM 2005,
353329-331 Alexi A. Wright, M.D., and Ingrid T.
Katz, M.D., M.H.S.
37
Newer technology doesnt eliminate error
38
Improving the System By
  • - Collecting,
  • - Analyzing, and
  • Sharing

Safety Information
39
The Tip of the Iceberg
Pledging for the consideration of more common
events in aviation.
(1) Serious
Accident
(15) Minor accidents with damage and
injury (300) Incidents and near misses (15 000)
Observed work errors
40
Flight Operations Monitoring concept
WHAT
WHY
Flight Surveys (LOAS)
Flight Data Analysis (FOQA)
Tools for Detection of deviations
What Why
Actions Flight Operations
Analysis Risk Assessment Decision making
Actions Training
41
Cockpit Crew 1 day Workshop
  • Situation Control
  • Transition training
  • Error management
  • Automation

simulator sessions briefings simulator
sessions debriefings
42
Improvement of security is cost-effective
  • Passenger/crew death and injury
  • Aircraft physical damage
  • Site contamination and clearance
  • Loss of aircraft resale value
  • Loss of aircraft use
  • Loss of staff investment
  • Loss of cargo
  • Search and rescue
  • Airline response
  • Accident investigation

43
Threats to Safety in Medicine
Organizational Organizational Culture Scheduling
Staffing Experience levels Work Load Error
policy Equipment issues
System - level National culture Health-care
policy and regulation Payment modalities Medical
coverage
Professional Proficiency Fatigue Motivation Cultur
e (Invulnerability)
Patient Primary illness Secondary illness Risk
Factors Atypical response to treatment Ongoing
management
Expected Events and Risks Unexpected Events and
Risks Well known and expected
44
Conclusion (1) Building a Safety Culture
  • Define a clear policy regarding human error
  • Accept error but not intentional non-compliance
  • Institute formal procedures where appropriate
  • Recognize the dangers in fatigue
  • Use confidential reporting systems to uncover
    threats and sources of error
  • Analyze near miss/adverse/sentinel
  • Provide formal training in threat and error
    management

45
Conclusion (2) Procedures
  • Standard Operating Procedures (SOP) were
    aviations first countermeasures against threat
    and error
  • Aviation is arguably over-proceduralized
  • Medicine is under-proceduralized
  • Example Checklists are critical error
    countermeasures

46
Conclusion (end) Training Topics
  • Human limitations as sources of error
  • The nature of error and error management
  • Culture and communications
  • Expert decision-making
  • Training in using specific behaviors and
    procedures as countermeasures against threat and
    error
  • Briefings
  • Inquiry
  • Sharing mental models
  • Conflict resolution
  • Fatigue and alertness management
  • Analysis of incidents and accidents
  • both positive and negative aspects
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