BIDMC Philosophy and Approach to Error

1. BIDMC Philosophy and Approach to Error

2. BIDMC Philosophy: • Errors are common; Health Care is Hazardous.

4. Why are Errors Common in Health Care? • Care involves multiple steps

5. Identification of Patients at BIDMC Example: ED to Floor RN Reg Staff Transport RN RN Lab RN Radiology MD Pt Access Transport/Lab/ Radiology , etc… … MD RN MD RN Reg Staff

6. Chance of completing a multi-step process without an error. Error Rate No. steps 1:100 1:1000 1:10,000 1 .99 .999 .9999 10 .90 .99 .999 20 .82 .98 .998 100 .36 .90 .99 100 .00004 .31 .89 10,000 - .000009 .26 20,000 - - .07

7. Why are Errors Common in Health Care? • Care involves multiple steps • Those steps involve Humans

8. Read this next slide . . .

9. Paris in the the Sring

11. Why Do Humans Fail? • Fatigue • Environmental Conditions • Task Design • Psychological conditions • Competing Demands

12. Why are Errors Common in Health Care? • Care involves multiple steps • Those steps involve Humans • Humans commonly make errors, especially under stress, or when information does not fit the expected pattern.

13. Nominal Human Error Rates for Selected Activities

14. BIDMC Philosophy: • Errors are common; Health Care is Hazardous. • We need to reduce the risk of error, predominantly by improving systems. • Accepting that errors cannot be eliminated, we need to • Learn from them • Manage the repercussions to the patient, caregivers, and any other affected groups.

15. Intent, Vigilance & Hard Work: 10-1 Performance • Common equipment • Standard orders sheets • Personal check lists • Feedback of information on compliance • Awareness and training

16. Learning From Error • Encourage reporting • Nonpunitive reporting policy • Easy Interface for reporting • RL Solutions Software • Department of Risk Management, staffed with 5 Patient Safety Coordinators • Review and learn from that which has been reported • Morbidity/Mortality • QI Directors • Patient Care Assessment Committee of the Board

17. Managing those Affected by Error • Full Disclosure to patients, as information develops • Support for clinicians • In performing disclosure • In dealing with their own reaction to error.

18. Our Goal: Learn about small problems before they become adverse events: Develop a system by which everyone in the organization consistently identifies barriers to work and care and implements solutions as close to real time as possible. Share learnings in a way that maximizes opportunity to improve quality and safety.