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Reducing Errors Preventing Injury Saving Lives Peggy G. Duke, M.D. Associate Professor Emeritus, Department of Anesthesiology Division of Cardiothoracic Anesthesiology – PowerPoint PPT presentation

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Title: Reducing%20Errors%20Preventing%20Injury%20%20%20%20%20Saving%20Lives

Reducing Errors
Preventing Injury Saving Lives
  • Peggy G. Duke, M.D.
  • Associate Professor Emeritus,
  • Department of Anesthesiology
  • Division of Cardiothoracic Anesthesiology
  • Emory University School of Medicine
  • September 15, 2015

Developing A Culture of Safety Easy to say, hard
to do
  • At the most fundamental level reducing errors in
    medicine requires a shift in paradigm
  • Unwavering commitment and accountability
  • Organizations leadership CEO, COO, CFO
  • Physician leadership
  • Nursing leadership
  • Departmental Chiefs
    Frontline personnel

Physician role in changing the culture
  • Acquiring new knowledge skill sets
  • Assuming leadership roles in quality initiatives
  • Making practice changes based on new knowledge
  • Monitoring changes and revising when necessary
  • Working collaboratively with administrative,
    quality team departmental, nursing and frontline
  • Helping develop evidence-based safety-driven

In Medicine
In building and sustaining a culture of
Physicians lack of ownership of quality
Errors Occur Worldwide with Alarming Frequency
  • Physicians, nurses, patients, all healthcare
    personnel, and hospital leaders need to
  • Grasp the scale of the problem
  • Accept that errors are common
  • Understand the need to change to a culture that
    views errors not as human failures but as
    opportunities to improve a faulty system

Institute of Medicine (IOM) 1999
Major Points
  • 1. 100,000 patients die in US hospitals annually
    as a result of medical errors
  • 2. 1 million excess injuries
  • 3. 70 of the adverse events are likely
  • 4. Problem of accidental injury is serious
  • 5. Cause is not careless people but faulty
  • 6. Priority redesign our systems to reduce
  • 7. Patient safety must become a priority
  • To Err is Human Building a Safer Health
    System Kohn LT, Corrigan JM, Donaldson MS,
    eds. Washington, DC
    National Academy Press 1999.

Annualized estimate of drug related errors
resulting in additional care in US (includes
non-hospital care, office visits, etc.)
  • 116 million extra visits to a physician
  • 76 million additional prescriptions
  • 17 million ER visits
  • 8 million admissions to hospital
  • 3 million admissions to long term care
  • 199,000 additional deaths
  • Total cost 76.6 billion/year
  • Am J Health Syst Pharm. 1997 Mar 1

2013 Estimated patient harm in US hospitals
  • Preventable
  • Deaths gt 400,000/year
  • Serious harm gt 4 - 8 million /year

Evidence-based estimate of patient harm In US
hospitals James J Patient Safety 2013 9
Errors are underestimated
4-8 X
  • Many errors do not produce injury
  • Some errors are caught before reaching patient
  • Many patients are incredibly resilient
  • Sometimes we---patient clinician-- get lucky

Medical errors occur Worldwide With
alarming frequency In all settings Cause
serious harm or death
  • Estimated that 10-20 of all health care
    encounters result in harm to patients

Basic Concepts of Human Error Reason, JT
1990 Cambridge, England Cambridge
University Press
  • Errors inevitable part of being human
  • Errors are made by highly skilled, highly
    intelligent, conscientious professionals who
    hold themselves to very high standards
  • Error primarily results from latent errors caused
    by flaws in systems processes
  • Design
  • Organization
  • Training
  • Management

Common Types of Human Errors
  • Omission failure to do
  • Missed diagnosis
  • Delayed evaluation
  • Failure to prescribe needed drug
  • Inadequate evaluation for respiratory depression
  • Commission doing the wrong thing
  • Giving wrong drug
  • Operating on wrong side
  • Ordering wrong drug/wrong dose
  • Giving opioid to patient with undiagnosed
    respiratory depression
  • Communication
  • Failure to give vitally important information,
    i.e., allergy, last dose of antibiotic,
    difficult airway

Lack of leadership at CEO other
levels Understaffing Inadequate equipment Lack
of resources Lack of physician
engagement Poorly designed processes
Inconsistent expectations Inexperience Poorly
trained Creating fear
Fatigue Distractions Fear to speak up
Gave wrong drug Forgot crucial detail at
handoff Gave wrong blood Forgot to do
diabetic foot , eye exam Inadequate
monitoring for respiratory
Incorporate proven safety principles
  • Train staff
  • Principles of human error
  • Quality improvement techniques approaches
  • Practice evidence-based or evidence-informed
  • Harness the use of forcing functions
  • e.g., e-prescribing with alerts and other
    computer assisted functions
  • Design team-based, protocol-driven approaches
  • Especially important in highly complex

Incorporate proven safety principles
  • Standardize
  • equipment, supplies, processes
  • Establish interdisciplinary teams
  • discuss safety issues problems in
    work environment
  • Understand your work environment
  • where are the breakdowns, bottlenecks, dangers?
  • Remove fear
  • everyone should feel safe to speak up when
  • Stop blame the person mentality
  • Systematically design safety into processes of

Incorporate proven safety principles
  • Develop checklists for handoffs
  • Read out loud, in order, check off as
  • Develop surgery procedural checklists
  • Read out loud, in order, check off as
  • Identify and communicate critical situations with
  • Repeat Back to Verify similar to airline
    safety instructions
  • RUNWAY SAFETY A Best Practices Guide
  • to Operations and Communications
  • Do not acknowledge the ATC instructions or
  • by using your call sign and saying Roger or
  • Instead read back the entire instruction or
  • including the runway designator and aircraft
    call sign.

Managing Human Errors
Blame the person (Traditional approach) AKA Naming, blaming shaming Blame the person (Traditional approach) AKA Naming, blaming shaming Systems Approach Assume faulty system design Systems Approach Assume faulty system design
Errors seen as caused by individuals Carelessness Inattention Poor motivation Forgetfulness Poor training Errors seen as upstream system process design flaws Look for weak links Add barriers to reduce chance of human error Accepts fact that one cannot change the human condition
Traditional approach has and will continue to fail to reduce human errors "Insanity doing the same thing over and over again and expecting different results. Albert Einstein Work in collaborative multidisciplinary teams Analyze the process Determine weak links Determine bottlenecks Determine high risk areas Reduces errors can lead to sustained change Strong support hard work can lead to a change in culture Culture of Safety gtgtgtgtgt Just Culture
Management strategy Write more policies Poster campaigns Disciplinary actions Re-train Fire the individual Support multidisciplinary teams Teach human error theory Teach systems approach Change the conditions under which humans work Design strategies/defenses to avoid/avert errors or mitigate their impact
  • Medical care very complex chain of processes
  • Aim to improve patients health and well being
  • Each link in chain can be associated with
  • No problem
  • Intermittent problems
  • Variation
  • Near misses (recognized or not recognized)
  • Safe throughput requires
  • Knowing where the weak links, high risk areas
    and dangers are
  • Having systems barriers that reduce likelihood
    of errors

Healthcare is more complex than any other
  • Overwhelming ongoing increase in knowledge
  • Technology increasing in complexity
  • Procedures increasingly more complex
  • Less continuity of care in hospitals multiple
    teams deliver care
  • More handoffs each handoff increases
    likelihood of error
  • Multi-tasking Interruption-driven environment
    Increasingly older, high acuity patients with
    little reserve
  • Pressure to perform more, faster and with less
  • One person providing care for multiple patients

Errors occur more commonly
  • When clinicians are inexperienced
  • New procedures are introduced
  • Patients at extremes of age(perhaps not more
    errors, just less resilient )
  • Patients requiring complex care
  • Prolonged hospital stays
  • Highly technical areas, i.e., OR, ICU, ER
  • In highly technical surgical procedures, i.e.,
  • surgery, neurosurgery, robotic surgery

You Dont Have to Reinvent the Wheel
  • Much work already done
  • Start with already identified error prone areas
  • Medication
  • Surgery
  • ICUs
  • Handoffs
  • Research lots of data about how to begin
  • Checklists
  • Computerized forcing functions
  • Computerized physician order entry
  • Team developed protocols

How might we apply error reducing principles to
an often overlooked but deadly problem
  • In-Hospital Cardiopulmonary Arrests (IHCA)
  • Specifically addressing a huge subset of IHCA
  • Postoperative Opioid Induced Respiratory

In-Hospital Cardiopulmonary Arrests (IHCA)
  • Up to 750,000 cardiopulmonary arrests annually in
    US hospitals
  • 80 of arrest victims do not survive to
  • Studies show 50 of those patients had been
    given opioids
  • Opioid induced respiratory depression
  • insidious
  • hard to diagnose using current technology
  • can lead to death or anoxic brain injury
  • occurs in very healthy patients
  • Overdyk, Guerra
  • American Nurse Today
  • 6(1)November 2011, 26-31

Consider The Subset Post-operative
Opioid-Induced Respiratory Depression (POIRD)
  • 3rd most common in-patient safety related error
  • gt50 postoperative respiratory events thought to
    be caused by opioids
  • Each institutions incidence may seem low---
    BUT--- that is misleading
  • 48 million in-patient procedures in US
  • Absolute number of POIRD events is significant
  • Unexpected death or brain injury can occur in
    even healthiest patients
  • Worse outcomes for respiratory events that occur
    on general nursing floor
  • Likely related to intermittent monitoring
  • Undetected respiratory compromise
  • Additional IV opioids /- sedatives
  • No significant change in patient outcome in past
    40 years

  • 2011 Our goal No Patient Shall Be
    Harmed By
  • Opioid-Induced Respiratory Depression
  • Dr. Stoelting, President
  • Anesthesia Patient Safety Foundation (APSF)
  • 2015 Anesthesiology, Closed Claims
    Analysis POIRD
  • Conclusion
  • Multifactorial
  • 88 occur within first 24 hours of surgery
  • Most events are preventable with
    improvements in
  • Assessment of sedation/consciousness
  • Monitoring of oxygenation
  • Monitoring of ventilation
  • Early response intervention

Closed Claims Analysis March 2015 Anesthesiology
Lee, Caplan
Medication factors Claims
Peripheral nerve blocks 0
Opioid given via gt 1 modality 50
Continuous opioid infusion 50
Opioids concurrent non-opioid sedating drug 33
Multiple physicians ordering opioids /- sedating drugs 33

Claims Timing of event
88 Within 24 hours of surgery
13 Within 2 hours of D/C from PACU

Claims Monitoring at time of event
50 No respiratory monitors
33 Non-telemetric SPO2

Excessive doses rarely the cause
Example Tragic Error from 2015 Closed Claims
  • 1st postop day Obese, otherwise healthy 46 year
    old male Described as sleepy, slow to arouse,
    snoring loudly
  • SPO2 read 49 on room air
  • oxygen cannula replaced, SPO2 soon 93
  • Described as being without complaints
  • 24 minutes later found apneic
  • Full code called
  • Died few days later with anoxic brain injury

We Cannot Continue As Usual
  • Large numbers of patients are still being harmed
    by postoperative opioids
  • POIRD often leads to death or anoxic brain injury
  • No change in patients outcomes for past 40 years
  • Monitoring SPO2 on general nursing floors is
    intermittent, if done at all
  • Monitoring respiratory rate alone is not adequate

Clinicians should be made aware
  • SPO2 is a monitor of oxygenation not ventilation
  • SPO2 can be misleading when a patient is on
    supplemental oxygen
  • SPO2 monitors are known to have significant
    number of false alarms
  • ETCO2 is misleading and inadequate in
    non-intubated patients
  • Respiratory rate does not detect inadequate
  • Monitoring ventilation
  • Tidal volume, minute ventilation and
    respiratory rate would be ideal

What Safety Lessons Can Be Learned from the
Closed Claims Analysis Data
  • Patients on opioids post operatively are high
    risk for POIRD
  • Continuously monitor oxygenation and ventilation
  • via telemetry or direct nurse call system
  • Use non-opioids analgesia when possible
  • peripheral nerve blocks
  • acetaminophen
  • ketorolac
  • Develop protocols that
  • Provide oversight by one physician-led team
  • With same goals knowledge of patient
  • For ordering opioids
  • For ordering sedating drugs
  • Do not allow opioids by more than one route
  • i.e., if using PCA, do not give additional opioid
    IV push

Reducing Errors in Medicine Requires Engaged
Physicians Leaders, Champions, and Supporters
  • Shake Up the status quo
  • Look at the data
  • Understand human error theory
  • Understand your system processes
  • Work in collaborative, multidisciplinary teams
  • administration, nursing, physician, quality,
  • Help develop support processes, protocols that
    drive safety
  • Walk the Talk, i.e., do what you ask others to
  • Physicians have the power to lead, change, and
    sustain a Culture of Safety

Culture of Safety Implies a Just Culture
  • Just Culture-------Trust is essential component
  • Collective understanding of where the line should
    be drawn between blameless and blameworthy
  • Accepts that
  • lt 10 of errors are culpable
  • gt 90 of errors are systems flaws
  • Can be reported without concern for reprisal or
  • Reduces fear in reporting
  • Allows learning from errors, near misses
  • Provides data to improve processes

Data and Data Analysis
  • Gather data about incidents and near-misses
  • Gather data about all cardiopulmonary arrests
  • Categorize manage harm with severity assessment
  • Conduct Root Cause Analysis (RCA) to find sources
    of errors
  • Create opportunities for learning from errors and
    near misses
  • Establish Clinical Pathways, (evidence-based,
    standardized patient management)
  • Establish protocols for high risk situations

Building a Safe Environment
  • Accept as a given
  • One cannot change the human predisposition to
    make errors
  • Know the possibilities
  • One can change the conditions under which humans
    work and reduce errors in the delivery of

It is Also About You, Me, and Those We Love
  • The urgency to decrease errors in healthcare
    should be readily recognized by anyone who
  • is likely to require care sometime in the future
  • is aging
  • or both
  • That anyone is each one of us our loved ones
  • Reducing Medical Errors A Marathon, Not a
  • 24 hrs./day X 7 days/week X 52 weeks/year

  • 1) Kohn, Corrigan, etal, eds, To Err is Human
    Building a Safer Health System, Washington, DC
    National Academy Press 1999.
  • 2) Am J Health Syst Pharm. 1997 Mar 1
  • 3) James Evidence-based estimate of patient
    harm, In US hospitals, J Patient Safety 2013 9
  • 4) Reason, JT , 1990 Cambridge, England,
    Cambridge University Press
  • 5) Anesthesiology 2010 POIRD-
  • 6) Lee, Caplan, 2015 Anesthesiology,
    Postoperative Opioid-Induced Respiratory
    Depression, Closed Claims Analysis
  • 7) Fecho K, Jackson F, Smith F, Overdyk FJ.
    In-hospital resuscitation opioids and other
    factors influencing survival.
  • Ther Clin Risk Manag. 20095961-968.
  • 8) Brady WJ, Gurka KK, Mehring B, Peberdy MA,
    OConnor RE American Heart Associations Get
    with the Guidelines (formerly, NRCPR)
    Investigators. In-hospital cardiac arrest impact
    of monitoring and witnessed event on patient
    survival and neurologic status at hospital
    discharge. Resuscitation. 201182(7)845-852.
  • 9) HealthGrades. The Sixth Annual HealthGrades
    Patient Safety in American Hospitals Study.
    fetyInAmericanHospitalsStudy 2009.pdf. Accessed
    August 22, 2012.
  • 10) Overdyk FJ. Postoperative opioids remain a
    serious patient safety threat. Anesthesiology.
  • 11) Peberdy MA, Ornato JP, Larkin GL, et al.
    Survival from in-hospital cardiac arrest during
    nights and weekends. JAMA. 2008 299(7)785-792.
  • 12) HodgettsTJ,KenwardG,Vlackonikolis,I , etal
    .Incidence,location and reasons for avoidable
    in-hospital arrest in a district general
    hospital. Resuscitation. 200254(2)115-123.