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Agenda

The closed loop : is it the end of errors ? Experiences with an identification information system Dr.med. Marc Oertle LA Medizin/Medizininformatik , Spital Thun. Agenda. Introduction Errors in healthcare The closed loop identification information system Idef -IS

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Agenda

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  1. The closedloop: isitthe end oferrors?Experienceswith an identificationinformationsystemDr.med. Marc OertleLA Medizin/Medizininformatik , Spital Thun

  2. Agenda Introduction Errors in healthcare The closedloopidentificationinformationsystemIdef-IS Resultsandconclusions

  3. The Spital STS company Regional, communitybasednon-university hospital 2campus 300 beds 16’000 inpatients 45’000 outpatients 1’200 employees CPOE, eMAR, AMDS established 2002-2003

  4. Errors in healthcare

  5. 5% ofinpatientssufferfrom(mostlyavoidable) complications Manynear-misses Someestimates (USA): Increasedlengthofstay (LOS): 2.9 – 4.5 due tomedicationerrors Average additional costs per complication: $5400.- But: let‘stalkabout e-iatrogenesis ! New andotherworkflows, different waytowork, paperpersistence, patternchanges in communication, lossofworkingroutines, emotions, technicalfailures, false positive alerts, neu failures due to ICT, changes in power structure …. Errors in healthcare (2)

  6. Transfusion relatedproblems(reportingbias...) CH und U.K. : near miss ~1/ 340-440 transfusion ABO-incompatibletransfusion: ~ 1:30‘000 Thun: ~ 5‘000 RBC transfusions/a : incompatibletransfusion~ 1/18-24 Monate… Under-reportingassumedtobemorethan relevant Transfusion-relatederrors

  7. Crossing the quality chasm • Followsthe IOM report „ToErris human“:Sixspecificaims • Safety • Effectiveness • Efficiency • Patient centred • Timely • Equitable •  ICT usagenearlyinevitable

  8. JCAHO aims 2004/05/06/07/08/09/10/11/12... - Spital STS AG CIRS :50% withrelationtomismatch / misidentification Überblick

  9. CIRS : Citations: „A blood sample cametothe Lab with different labels on theorder form an thetube»(paperera) «A blood sample cameintothe lab with a wronglabel (barcodeformedication) on thetube» „Patient in thewrongbed: the IMC personnelldiscoveredthemismatch after havingsenttheblood sample tothe lab» „The GP referredpatient X for a specifictesttotheemergencydepartment (…). Blood sample was takenandsenttothe lab. Later, the GP calledthephysician on duty an d toldhimthat he hassentthewrongpatient. The correctpatientarrived 2 hourslater . „ CIRS backgrounds Strategie

  10. Right patient Right time Right plan (to act): prescription e.g. Right action Right resource Right person Right place Aim: the 7 R Qualitäts- und Prozessmanagement

  11. Maximizingprocessquality Maximizingprocessknowledge Maximizing ROI  7R + 3M=quality Further aims: the 3M

  12. Can youquantify a humans‘ life ? Costs due tocomplications/adverseevents, morbidity Reductionoflifeexpectancy QALY (LE x f) und costs per QALY Return on investment Qualitäts- und Prozessmanagement

  13. 96% agreecompletely, but some : „Personally I thinkyoushould just labelmewith a chipor a barcodewhen I shouldbecomeunconsciousorsufferfromseveredementia. Otherwise I will beabletoverifythenursesactivities“ „I‘mworryingaboutthedatabeingstored in thesecodesorchips“ „I will getsomeinfusionsand iv linesandthewristbandcouldpreventnursesfromdelivering proper care “ „In ourreligiouscommunity, barcodesare a diabolicalsign! I wouldrefuseanylabelslikethatandprobably not cometoyour hospital anymore“ Whatarepatientsthinkingofidenficiation Sozio-technisches Umfeld

  14. One additional pieceof Swiss cheese …

  15. EAN = unambiguous Idef-IS architecture

  16. Initial hardwareIdef-IS 2006

  17. Hardware 2013 «Vaccination» «Identification»

  18. Medikamente/Blutentnahmen/ECK prüfen Barcode blood sample Barcode medication Blood products Patient

  19. Closedloopsystem: bloodsamples/transf.

  20. Closedloopsystem: medication

  21. Main problems • Mobility... • Mobility... ...withfullneedofinformationandcontrolofprocesses • WLAN-readiness, real-time availabilityofdata • handiness, weight, hygiene, size, shockproof • Stabiliy (WLAN, hardware, craddles, dockingstations) ,... • Diversityofproducts not given • Workloadnurses, Compliance, perceivedusefulness • Thefts, dataprotection, highlysecured WLAN • Prizes (RFID, IT personnel) • But not: • Homemadesoftware • Seamlessintegrationintoclinicalinformationsystem • IT Support • Patient Besten Dank

  22. Das Identifikations-Informationssystem IDEF-IS On dayslikethese…

  23. Let’stalkabout relative numbers…

  24. Avoidedandthusnearmisses Last 12 months 1’313 transfusionsverified (out of 2’505 inpatient-RBC-transf.) : 52% 4 mismatch-warnings (2 false positive due to Lab system) 2 / 1313 = 1.5 %o Still: selectionbias?!….

  25. Completelysafe? NO ! IDEF-IS as an additional element in thesafetychain/management The completesafety: zeromistakes will never happen Technical tightrope-actwithmany (vulnerable) components Hugeeffortsnecessarytoreduceseldomevents. But: thistransfusionerrorcouldbethelethalone… Don’tforgetthe «non-electronic» safetymeasures (double control) in caseof non-function/non-availabiltyofthe electronic safetysystem !

  26. Incompetent people are, at most, 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it's the processes that set them up to make these mistakes. Dr. Lucian Leape, Harvard School of Public Health Last but not least

  27. The closedloop: isitthe end oferrors? NO !But the end ofsome (near) misses…

  28. Discussion , questions Idef-IS

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