Patient Safety

2. Patient Safety • What is it? • Why is it important? • What are we doing? • What is my part to play?

3. Patient Safety: What Is It? Error -- Failure of a planned action to: • be completed as intended or • use of a wrong plan to achieve an aim

4. Patient Safety: What Is It • Unsafe care can result from: • Fragmented health care system • Faulty systems • Increasing complexity • Lack of awareness of extent of the problem • Culture of individual focus and blame • Lack of systemic view

5. Patient Safety: Why Is It Important? • Institute of Medicine report sites studies: • Medical errors occur in 2.9% to 3.7% of hospital admissions. • 8.8% to 13.6% of errors lead to death. • Between 44,000 and 98,000 deaths occur each year in hospitals as a result of medical errors.

6. Deaths Due to Preventable Adverse Events in Hospitals • Using lower number (44,000), 8th leading cause of death in the United States • Exceeding • Motor vehicle accidents (43,458) • Breast Cancer (42,297) • AIDS (16,516) Institute of Medicine report

7. Cost of Medical Errors • 459 adverse events identified from 14,732 randomly selected discharges at an estimated health care cost of $348 million. (Not including cost of loss income, disability, etc.) • 265 of the 459 adverse events found to be preventable, which represents $159 million in health care cost. Institute of Medicine report

8. Cost of Medication Errors • Most do not result in harm but those that do are costly. • Recent study: 2% of admissions have a preventable adverse drug event resulting in: • increased LOS of 4.6 days • increased hospital cost of $4,700 / admission • totals $2.8 million for 700-bed teaching hospital. Institute of Medicine report

9. Medications Administered in Allina • More than 7 million doses of medications are administered per year in Allina Hospitals and Clinics. • Is there an acceptable medication error rate? • A 1% error rate would allow 70,000 errors. • A 0.5% error rate would allow 35,000 errors. • A 0.1% error rate would all 7,000 errors. • Our goal is a fail-safe system that is free of errors

10. This Doesn’t Happen Here. Does it?

11. This Doesn’t Happen Here. Does it?

12. Patient Safety: What Are We Doing? Allina Hospitals and ClinicsPatient Safety Vision: Achieve patient care environments free of accidental injury.

13. Safe Delivery Principles • Standard processes for doses, dose timing and dose scales • Standardized prescription writing • Limit number of different kinds of common equipment • Implement physician order entry • Implement decision support (eg drug dose; drug-allergy) • Unit dosing • High risk IV supplied only by central pharmacy • Written protocols for high risk medications • No KCl on care units • Pharmacist on rounds • Patient information available at point of patient care • Allergy wristbands • Computer generated MARs • Bar coding

14. Swiss Cheese Model Defenses Against Errors Hazards Ideal Reality Errors J. Reason

15. Action: Create a Safety Culture That . . . • understands systems and how errors happen • incorporates human factors research • expects learning, not blame • designs safe systems

16. Action: Allina Patient Medication Safety Task Force Goals: • Increase awareness of unsafe systems. • Implement mechanisms to allow learning from errors. • Establish the principles of safe systems. • Initiate and complete rapid cycle improvements in our systems. • Improve reporting including near misses.

17. Patient Safety -What Is My Part to Play? • Practice Principles of Patient Safety • Report • Identify unsafe systems and take action to protect the patient