Understanding Medical Errors: Challenges and Solutions for Patient Safety

1. Mistakes in Medicine Thomas H. Gallagher, MD University of Washington School of Medicine

2. Errors & Adverse Events Are Unavoidable • Health care is fundamentally a human enterprise • High profile errors • Wrong site surgery, mismatched transplant, massive chemotherapy overdoses • Evolving patient safety movement • Systems approach to errors • Open communication when errors occur • How we respond to errors affects important patient outcomes

6. Definitions • Medical error: “Failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim.” • Adverse event: “Injury that was caused by medical management and that resulted in measurable disability.”

7. Relationship of Errors and Adverse Events Medical Errors Adverse Events (complications) Non-preventable AEs Potential AEs Preventable AEs Near Misses

8. Bad Apple Paradigm • Errors thought to be due to healthcare workers who are incompetent or lazy • Improve quality by inspection: find and remove bad apples from barrel • Bad apple paradigm creates culture of blame and shame • Healthcare workers hide errors

9. Patient safety paradigm • Errors due mostly to defective care systems • Errors as treasures • Emphasis on study of near misses • Importance of open communication among healthcare workers regarding errors

10. Accelerating Interest in Disclosure • Growing experimentation with disclosure approaches • Healthcare organizations • Malpractice insurers • New standards-NQF and others • State laws re disclosure, apology

11. Disclosure Performance Gap Also Increasingly Evident • Harmful errors often not disclosed • When disclosure does take place, often falls short of meeting patient expectations • Little prospective evidence exists regarding what disclosure strategies are effective • Impact of disclosure on outcomes unclear

13. Rationale for Disclosing Errors to Patients • Error disclosure as informed consent • Positive obligation to inform patients of errors • Error disclosure as truth-telling • Regulatory requirements • JCAHO standards, state laws • Disclosure gap • Blendon study: 30% disclosure rate

14. Ethical Complexities in Error Disclosure • Should I disclose: • Errors with minor/transient harm? • Fatal errors? • Harmful errors in patients who are hopelessly ill? • Other doctors’ errors?

15. Challenges for Trainees • Concern about impact of mistake on evaluation, reputation • Concern about impact of disclosure on patient’s trust • Limited formal training in disclosure • Power differential between trainees, attendings

16. Patients’ Attitudes about Errors • Patients conceive of errors broadly • Desire full disclosure of harmful errors • Worry that health care workers might hide errors

17. Physicians’ Attitudes about Errors • Define errors more narrowly than patients • Agree in principle with full disclosure • Want to be truthful, but experience barriers to disclosure

18. Physician Surveys • Survey of: • 2,000 physicians at Washington University/BJC HealthCare, University of Washington, Group Health Cooperative • 2000 Canadian physicians • 889 trainees at Wash U, UW • Topics: Communicating about medical errors with patients, colleagues, and health care institutions • Response rate: 63%

19. Insulin Case Hyperkalemia Case Sponge Case 65% 34% 96% “Definitely disclose” 71% 40% 14% Say “error” 43% 35% 9% Full apology Physicians’ Disclosure Attitudes

20. Additional Survey Findings • 64% unaware of hospital error reporting system • 19% agreed that systems to disseminate error information to physicians are adequate • 10% agreed that hospitals adequately support them after errors

21. Residents’ Error Experiences • 45% reported involvement in a serious error, 73% involved in minor error • 34% had disclosed a serious error to a patient, 63% had disclosed a minor error • 31% had prior training in disclosure • 90% desired disclosure training, 97% desired just-in-time disclosure coaching

22. Survey Conclusions • Physicians support concept of disclosure • Little agreement exists regarding the core content of disclosure • Less information disclosed for errors that would not be apparent to patient • Medical and surgical physicians may approach disclosure differently • Unmet needs for emotional support after errors • Disclosure training needed

23. Scenario 1: Insulin Overdose You have admitted a diabetic patient to the hospital for a COPD exacerbation. You handwrite an order for the patient to receive “10 U” of insulin. The “U” in your order looks like a zero. The following morning the patient is given 100 units of insulin, ten times the patient’s normal dose, and is later found unresponsive with a blood sugar level of 35. The patient is resuscitated and transferred to the intensive care unit. You expect the patient to make a full recovery.

25. Disclosure as institutional responsibility Best model? Train the trainer? Rely on physicians? Coaching? Disclosure as a team sport Interprofessional issues Integrating trainees Linking disclosure and compensation Emerging Institutional Disclosure Issues

26. Interprofessional Issues in Disclosure • Disclosure conceptualized as doctor-patient conversation • We make errors as teams--should we disclose them as teams? • Team disclosure complicated by power dynamics

27. Stages in Team Disclosure • Team discussion of error • Disclosure planning • Disclosure to patient

28. Case • Patient admitted to neuro ICU with recurrent seizures of unclear etiology • Loaded with Dilantin 300 TID, switched to 300 QD • Physician writing transfer orders to floor mistakenly writes for Dilantin 300 TID • Medication error not noticed by nursing, pharmacy • Patient falls, hits head; Dilantin level 29. Head CT normal • Patient worried that another seizure caused her fall

29. Error Discussion & Disclosure Planning

30. Disclosure 101 • Patients need • Truthful, accurate information • Emotional support, including apology • Follow-up, potentially compensation • Healthcare workers need • Disclosure coaching • Emotional support • Process, not an event • Initial conversation • Event analysis • Follow-up conversation

31. Key Disclosure Content • What happened, implications • Was event preventable (due to error) • Why event happened • How recurrences will be prevented • Apology • Expression of sympathy for all adverse events • Full apology when adverse event due to error • Plans for follow-up

32. Key Considerations for Students • Always tell your attending if you think there may have been an adverse event or error • Disclosure is attending’s responsibility • Learn more about patient preferences for disclosure, disclosure barriers and how to overcome them. • Attend to your own emotions after mistakes • Seek opportunities to learn, practice disclosure