Patient Safety 101

1. Patient Safety 101 North American Spine Society The North American Spine Society (NASS) is the leading multidisciplinary organization advancing quality spine care through education, research and advocacy. NASS has had an active patient safety program since 2000. This presentation provides education on patient safety and its basic concepts.The North American Spine Society (NASS) is the leading multidisciplinary organization advancing quality spine care through education, research and advocacy. NASS has had an active patient safety program since 2000. This presentation provides education on patient safety and its basic concepts.

2. North American Spine Society Patient Safety Basic tenet since Hippocrates� �first do harm� Modern medical advances provide sophisticated, effective treatments Also are complex, multifaceted with potential for errors in judgment, technical misadventure & system failure Patient safety has been a basic concept of medicine since its inception. As medical care has become more complex, so has patient safety.Patient safety has been a basic concept of medicine since its inception. As medical care has become more complex, so has patient safety.

3. North American Spine Society Types of Errors Medication (harmless-harmful-lethal) Wrong-site/procedure/patient surgery Miscommunication Transfusion events MRI safety Ineffective clinical alarms Examples: -(2003) Death of Jessica Santillan due to blood type mismatch of donated organs -(2002) Death of young boy in NY due to metal oxygen container entering MRI suite -Recent stories of removal of wrong limb -(1994) Death of Boston Globe health reporter, Betsy Lehman, due medication error related to chemotherapy -Insert your own examplesExamples: -(2003) Death of Jessica Santillan due to blood type mismatch of donated organs -(2002) Death of young boy in NY due to metal oxygen container entering MRI suite -Recent stories of removal of wrong limb -(1994) Death of Boston Globe health reporter, Betsy Lehman, due medication error related to chemotherapy -Insert your own examples

4. North American Spine Society How It Started: IOM Report To Err is Human-Much publicized Institute of Medicine Report-1999 �At least 44,000� and possibly �as high as 98,000� die in US annually due to �medical errors� 8th leading cause of death in US Perspective: Car accidents 43,458 Breast Cancer 42,297 AIDS 16,516

5. North American Spine Society Criticisms of the Report Origin of numbers-National figures for deaths extrapolated from only 2 studies Retrospective nature of reviews Suggestion that deaths due to medical errors were exaggerated

6. North American Spine Society Impact of the Report Major media splash Cries of shock & horror from the public, Capitol Hill Led to call for reporting systems AHRQ budget increased by $20 million This report was the beginning of a tremendous amount of interest generated in patient safety. It has led to much proposed legislation since its introduction, new accreditation standards on patient safety from JCAHO and a generally increased awareness of safety issues.This report was the beginning of a tremendous amount of interest generated in patient safety. It has led to much proposed legislation since its introduction, new accreditation standards on patient safety from JCAHO and a generally increased awareness of safety issues.

7. North American Spine Society Impact Focused national attention on patient safety and heightened awareness of public, health care providers, professional societies, hospitals, government.

8. North American Spine Society Valid Issues of IOM We know medical errors do occur Example-wrong-site surgery. Since 1995, 232 incidents reported to JCAHO. Probably underreported. Highlighted issues of reporting, analysis and error reduction.

9. North American Spine Society Parallels to Aviation Safety Pilot Co-pilot Crew resource management Doctor Allied health Medical teams Now to look at some basic concepts in patient safety: -Unlike in medicine, where sometimes medical team members are hesitant to question a doctor, crew resource management training is required for all airline crews. Co-pilots are required to question the decisions of pilots if they believe safety is at issue. The safety of the passengers is considered paramount and concerns about hierarchy of command come second. -Standardization example: use of checklists with every take off and landing. Similar to wrong-site surgery prevention checklists. -FAA has confidential incident reporting of errors and near misses. -NTSB/FAA investigation of accidents. Similar to root cause analysis used to investigate medical errors.Now to look at some basic concepts in patient safety: -Unlike in medicine, where sometimes medical team members are hesitant to question a doctor, crew resource management training is required for all airline crews. Co-pilots are required to question the decisions of pilots if they believe safety is at issue. The safety of the passengers is considered paramount and concerns about hierarchy of command come second. -Standardization example: use of checklists with every take off and landing. Similar to wrong-site surgery prevention checklists. -FAA has confidential incident reporting of errors and near misses. -NTSB/FAA investigation of accidents. Similar to root cause analysis used to investigate medical errors.

10. North American Spine Society Medical Error Reporting IOM recommended mandatory reporting Fear of litigation a significant impediment to meaningful reporting Due to fears of litigation, employer condemnation and punishment, many health care providers will not come forward to report medical errors in the current environment where they are not guaranteed confidentiality or legal protections.Due to fears of litigation, employer condemnation and punishment, many health care providers will not come forward to report medical errors in the current environment where they are not guaranteed confidentiality or legal protections.

11. North American Spine Society NASS Position NASS believes nonpunitive, confidential reporting is an important preventive measure. The goal of nonpunitive, confidential reporting is to identify errors, including near misses for correction & prevention� NOT PUNISHMENT OR LIABILITY This is the only way to encourage people to come forward and report errors. Punishment and liability only drive errors further underground where they cannot be corrected.This is the only way to encourage people to come forward and report errors. Punishment and liability only drive errors further underground where they cannot be corrected.

12. North American Spine Society Six Sigma QualityBorrowing from Industry Coined by Motorola to set tolerance limits in manufacturing Six sigma quality=error limit set 6 standard deviations above the mean on a normal distribution curve. High quality standard = >3.4 defects per million opportunities. ? sigma= more defects. ? sigma fewer defects.

13. North American Spine Society Six Sigma Examples Airline Operation 5 sigma for fatalities=230 deaths per million opportunities 4 sigma for baggage handling= 6,210 lost bags per million opportunities Health Care Anesthesia death rate between 25-50 per million opportunities in �70s & �80s After clinical guideline adoption, rate is 5.4 deaths per million opportunities. Close to 6 sigma quality.

14. North American Spine Society Medical Errors as Systems Problems Concept: System failures�not individual human failures� are to blame. Systems can be designed to back up human error (the sometimes imperfect human memory). A chain or system of related events that leads to an error; not caused by one individual.A chain or system of related events that leads to an error; not caused by one individual.

15. North American Spine Society An example of how a series of events can line up to produce the right circumstances for a medical error to occur.An example of how a series of events can line up to produce the right circumstances for a medical error to occur.

16. North American Spine Society Name, Shame & Blame Naming the error, shaming & blaming individuals has not reduced errors. Key to improvement is a learning health care system of 8 components.

17. North American Spine Society Learning Health Care System Informatics for information Guidelines as learning tools Learning from opinion leaders Learning from the patients Decision support systems Team learning Learning organizations Just in time and point of delivery care

18. North American Spine Society What to Do? IOM Recommendation Professional societies should make a visible commitment to patient safety by establishing a permanent committee dedicated to safety improvement and promoting a culture of safety� The release of the IOM report and the subsequent flurry of media attention and legislative initiatives stimulated NASS and other professional medical organizations to institute a more formal evaluation of the area of patient safety.The release of the IOM report and the subsequent flurry of media attention and legislative initiatives stimulated NASS and other professional medical organizations to institute a more formal evaluation of the area of patient safety.

19. North American Spine Society What Your Organization Can Do Patient Education Medical Professional Education (journal articles, publications, CME) Research adverse events & their causes in your specialty Make patient safety a research funding and advocacy priority Join with related organizations in safety efforts

20. North American Spine Society For more information, contact: North American Spine Society (815) 675-0021 www.spine.org