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خطاهاي پزشكي Medical Errors تيم مدرسان حاكميت باليني دفتر مديريت بيمارستاني و تعالي خدمات باليني - PowerPoint PPT Presentation


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خطاهاي پزشكي Medical Errors تيم مدرسان حاكميت باليني دفتر مديريت بيمارستاني و تعالي خدمات باليني وزارت بهداشت، درمان و آموزش پزشكي. مباحث این جلسه. مفهوم خطاهای پزشکی انواع آن میزان و شدت آن عوارض آن نگاه فردی و سیستمی به خطاها علل خطاها و روش های پیشگیری. 20 Aug. 2010. 3.

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خطاهاي پزشكي Medical Errors تيم مدرسان حاكميت باليني دفتر مديريت بيمارستاني و تعالي خدمات باليني

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Medical Errors


20 Aug. 2010

3


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JAMA: . Barbara Starfield :

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( ) .


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-2 .

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Cont.

230 284 225 .

- . .


Cont.

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.1

.2 . .

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4 18 .

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Cont.

20 30 ( ) .


Medical Errors statistics

  • .1 IOM(Institute of medicine):

    • 98-44 ( 195 )

    • 500

    • 6/37 17

  • .2 6

  • .35

  • .410% .


Cont.

  • .513% .

  • .5.659% .

  • :Adverse Events .7

  • 70% Adverse Events .

  • 6% Adverse Everts .

  • 24% Adverse Everts .

  • 8. 160 .


Cont.

ICU 16000

32000 .

8 .


Cont.

7000 Sloppy .

5/7 .

50.000 .

42% .


  • :


Clossification Quality interagency coordination Task force (QUIC) 5 Schemes :


Cont.

1- ( ......... )

2- ( ... )

3- Legal definitions ( ) ( negligenee malpractice ...)

4- ( ICU ...)

5- ( ... )


Cont.

:

:

. .


Cont.

.


.


Event (incidents)

1 - .

  • 2 - NHS : .

  • 3-


Classifications

  • 1- Errors

  • 2- Preventable Adverse

  • 3- IncidentNO Harm

  • 4- Near Miss/close call/ potential Adverse Event

  • 5- Hazard

  • 6- Harm

  • 7- Violtion


Error

  • .1(Executive):

  • .2 (Plan):

  • Accident


() Contributary Factors

  • :

  • .1 (CDP)

  • Care Delivery Problems( )

  • .2 (SDP)

  • Service DeliveyPnoblems


  • Iufluencing Factors

  • Causative Factors


Iufluencing Factors

  • .

  • :

  • .


Causative Factors

:

  • :

  • 1- .

  • 2- . Root Cause Analysis-(RCA)


  • 1- HumanError

  • 2- knowledge-basad

  • 3- : Role-based

  • 4- :Skill-base


Human Error .1

  • .

  • .


.2Knowledge-based Errors

  • .


.3 Rule-based Errors


.4Skill-based Errors


  • .1

  • Error of commision

  • ( )


Cont.

  • .2 Error of omision

  • () (Hip Replacement)


Cont.

  • omision commision .

  • ( 2 1)


  • 1- Active Failures

  • (Human-Machine interface)

  • 2- Latent Errors


(Human-Machine interface) ActiveFailures

  • 1- .

  • 2- .

  • 3- (- )

  • 4- ((Sharp End Scalpet

  • :


Cont.

  • ( )

  • :

    • ( )

    • ( )


Latent Errors

  • ( )

  • ( Blunt Of Scalpel)

  • .


  • :

  • :


Preventable Adverse Events

  • :


Adverse Event

  • 1-

  • Sentinel Event (Misadventure)

  • 2- No Harm Event

  • 3- Near Miss


Near- Miss /Close Call/ Potential Adverse Event

  • .

  • (Good Fortune Reasons)

  • ( )

  • ( .)

  • Recovery of Identification


No Harm Event

  • (No Actual Harm)

  • .


Sentinel Event (Misandventure)

:

(Death/Harm)

.


cognitive psychology of Task- oriented behavior

.1Error of Execution

  • Slip

  • Slapse

    .2 Error of planning


Behavior

  • .1 Attentional Behavior

  • 2- Autopilot- Schematic B.))


Mistake

Definitions

Attentional


Cont.

Reasons:

  • ( )

  • : 1-

    2- ()


Slips / Slapse

: Schematic

Executive

Slips

Slapses


Examples

(Slips )

( ) (Slips )

(Slapses )


Violation

( )

Short cut

:

1- Reasoned V.

2- Reckless V.

3- Malicious V.


Cont.

  • Reasoned V.

  • Reckless V.

  • Malicious V.

    • Acts OF Sabotage


:

Underuse

Overuse

( ) Misuse


Underuse

:

1-

1.1 21. 31. ( Screening)

2-

2. 22.


(Overuse)

  • :

  • 1- :

  • 2- (Paraclinic)

  • 3-


: Misuse

:

1- ( Rash )

2- ( )


Root Cause Analysis

* : .

[1] PersonApproach

[2] System Approach .

:


1- Personal Approach

  • .1 .

  • 2. ( ) .

  • .3

  • .4 .

    • .


Cont.

  • .5

    • .6 .


( ...) .

.


.

.

.


.

.

( ...) .

.


Cont.

.

.


2- : System Approach

.

.

.


Swiss Cheese Model James Reason

.

: .

.

( ) .


Cont.

.

:

1-

2- ( )


No single barrier is foolproof

()

( ) .

: ( )


Cont.

:

1- .

2- .

3- () Hang it Backward

4- ( )

5-


Important

.


* Root Cause Analysis

( ...) .

.

.


  • RCA

    • .

  • .

  • .


1- Organization Factors

.

.


2- Technical Factors

  • .


3- Human Factors

. Cognitive .

. Automatic SolvingProblem.


Automatic, Autopilot

:

.

.


Cont.

Executive Slips Slapses .

... .

.


Solving Problem

  • .

    • .

  • Plan Mistake .


Cont.

:

( )


:

1- ( )

2- Specialization Fragmentation

.

3- over work burnout


Cont.

4- ( )

5 Intravenous Pump ( )

6- : . .

7- :

.


Cont.

.8

.9

.10

.11 ( )

.12


.

:


Cont.

  • 1 . .


Cont.

  • 2 . .


Cont.

3 .


Cont.

4 : ... : ...


Cont.

  • : : : ... . .


Cont.

  • 5 ( ...)

  • 6 ( ) .


Cont.

  • 7 .

  • 8 : .


Cont.

9 : ... 10 ! : !


Never Events

National Quality forum 28 .

They are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability."

The 28 Never Events are:


Cont.

A recent Leapfrog Group Study finds that roughly half of the 1,285 hospitals that responded to their survey waive fees for never events, and that hospitals that do waive fees are much more likely to have perfect scores on the Leapfrog Safe Practices Score survey.


)

1. Surgery performed on the wrong body part

2. Surgery performed on the wrong patient

3. Wrongsurgical procedure performed on a patient

4. Unintended retention of a foreign object in a patient after surgery or other procedure


Cont.

6. Intraoperative or immediately post-operative death in an ASA Class I patient

7. ( ) Artificial insemination with the wrong donor sperm or donor egg


)

1- Patient death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the healthcare facility

2- . Patient death or serious disability associated with the use or function of a device in patient care, in which the device is used or functions other than as intended

3- Patient death or serious disability associated with intravascular air embolism that occurs while being cared for in a healthcare facility


)

1- Infant discharged to the wrong person

2- ) 4 Patient death or serious disability ( associated with patient elopement (disappearance)

3- Patient suicide, or attempted suicide resulting in serious disability, while being cared for in a healthcare facility


)

1-

Patient death or serious disability associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation or wrong route of administration)

2- ( ) Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO/HLA-incompatible blood or blood products

3- Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy while being cared for in a health care facility


Cont.

4- . Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility

5- ( Kernicterus ) Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates

6- 3 4 Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility

7- manipulative Patient death or serious disability due to spinal manipulative therapy


)

1- Patient death or serious disability associated with an electric shock or elective cardioversion while being cared for in a healthcare facility

2- Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances

3- Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility


Cont.

4- Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility

5. Patient death or serious disability associated with a fall while being cared for in a healthcare facility


)

1- Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider

2- Sexual assault on a patient within or on the grounds of the healthcare facility

3- Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility

4. Abduction of a patient of any age


Four Actions

The Leapfrog Group offers four actions as industry standards following a never event:

1)apologize to the patient,

2) report the event,

3) perform a root cause analysis, and

4) waive costs directly related to the event.


5 ( )Five Steps to Safer Health Care

1- . . Speak up if you have questions or concerns.

2- Keep a list of all the medicines you take. .

3- . Make sure you get the results of any test or procedure.

4- . Talk with your doctor and health care team about your options (choices) if you need hospital care.

5- . 5. Make sure you understand what will happen if you need surgery.


  • 1-

    • ( 96% 4% )

    • ( )

  • 2-

  • 3-


Cont.

:

...


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Cont.

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: ) ) ) ( .)) .


:

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