The Epidemiology of Patient Safety and Medical Error

1. The Epidemiology of Patient Safety and Medical Error WVU Department of Family Medicine RCB HSC-Eastern Division Konrad C. Nau, MD

3. “Man's heart stops after Bettis fumble” – Pittsburgh Tribune

4. “Man goes into cardiac arrest at Cupka's bar, in the South Side”

5. “Man's heart stops after Bettis fumble” – Pittsburgh Tribune

6. “Man's heart stops after Bettis fumble” – Pittsburgh Tribune

7. “I made a mistake. It’s my job to protect the ball – Jerome Bettis

8. Why all this fuss about Patient Safety ?

9. Prevalence • Average of 1.7 mistakes per patient per day in ICU (out of 200 patient-care activities) • 1% failure rate is too high to be tolerated • At 99.9%, there would be two unsafe plane landings at O’Hare airport each day, U.S. post-office would lose 16,000 pieces of mail, and 32,000 bank checks would be deducted from wrong accounts every hour — From Lucien Leape

10. Aviation Model : Error Happens

11. Aviation Model : Error Happens • 1903 First Powered Flight • 1908 First Pilot dies • 1910 First mid-air collision • 1918 31 of first 40 US Air Mail pilots die in crashes • 1994 4 crashes/10,000,000 takeoffs

12. Patient Safety • The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care. • These events include "errors," "deviations," and "accidents." • Safety emerges from the interaction of the components of the system; it does not reside in a person, device or department. (Cooper, et al)

13. Patient Safety • Freedom from accidental injury • establishment of operational systems and processes that • minimize the likelihood of errors • maximize the likelihood of intercepting them when they occur. (Kohn)

14. Patient Safety • actions undertaken by • individuals • organizations • to protect health care recipients from being harmed by the effects of health care services. (Spath)

15. Patient Safety Vocabulary • Adverse Event • Injury the results from medical care • Preventable Adverse Event • Error, could/should not have happened • Non-Preventable Adverse Event • Could not have been predicted or foreseen • Potential Adverse Event • “Near miss” or “close call” • No harm done…error intercepted

16. Patient Safety Vocabulary • Error • the failure of a planned action to be completed as intended • the use of a wrong plan to achieve an aim.

17. Medical Error Medical Errors Any error in the health care delivery process

18. Adverse Event AE Injury that results from medical care, not a part of the natural disease process

19. Adverse Events Non-preventable Adverse Events Medical Errors AE Preventable Adverse Events

20. Near Miss Near Miss- Potential Medical Error Intercepted error Medical Errors Near Miss

21. Medical Errors & Adverse Events Non-preventable Medical Errors AE Near Miss Preventable AE Serious Medical Errors

22. Defenses Potential Adverse Event DANGER Hazards A Generic Model of Safety Defenses can be hardware (e.g., monitors), people (e.g., nurses) or administrative (e.g., acceptable protocols) (From Managing the Risks of Organizational Accidents, Reason, 1997)

23. Defenses Potential Adverse Event DANGER Hazards A Near Miss Usually several defenses must fail to cause an accident— Just one remaining intact is enough to prevent a near-miss becoming an accident…

24. Defenses Adverse Event DANGER Hazards A Harmful Event What is “the cause”? The hazard? Failure of which defense? This is the problem with assigning single causes…Blame/cause often is assigned to the last barrier [usually a person] to fail!!

25. Observed Path to Schedule and Complete a Doctor’s Appointment

26. Quality and Error

27. To Err is Human • Process • People

28. To Err is Human • Process ………85% • People………..15%

29. Errors are Treasures • Every process is perfectly designed to achieve exactly the results it gets. • As long as we keep on doing what we keep on doing, we’ll keep on getting what we’ve got .

30. The Swiss Cheese Model of Safety Layers of Protection Some holes due to active failures Hazards Other holes due to latent conditions Adverse Event

31. When all the holes lined up Elevated PT INR Lab tech Resultto office nurse Physician interprets Patient Falls – Cerebral Hemorrhage Patient contacted

32. Errors • “Most organizational errors are made by well-intentioned human beings—most highly educated, well trained, well intentioned human beings—who become accustomed to small glitches, routine foul-ups, and a culture that suppresses doing much about them in the name of an overriding goal.” • James Reason – Internal Bleeding

33. Latent Errors • Latent errors = process or system failures • Pose the greatest threat to safety in a complex system because • Lead to operator errors. • They are failures built into the system and present long before the active error. • Latent errors are difficult for the people working in the system to see since they may be hidden in computers or layers of management • people become accustomed to working around the problem

34. Six Changes That Save Hospital Patient Lives • Deployment of Rapid Response Teams…at the first sign of patient decline • Delivery of Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack • Prevention of Adverse Drug Events (ADEs)…by implementing medication reconciliation • Prevention of Central Line Infections…by implementing a series of interdependent, scientifically grounded steps called the “Central Line Bundle” • Prevention of Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time • Prevention of Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps called the “Ventilator Bundle”

35. Ambulatory Care is different • Care is brief and episodic from the providers point of view • Patients and clinicians have many degrees of freedom • Feedback loops are long • Adverse Events are often not directly seen or even reported

36. Learning from Different Lenses:Reports of Medical Errors in Primary Care by Clinicians, Staff and Patients Robert Phillips John Hickner Deborah Graham Susan Dovey Nancy Elder A Project of the AAFP National Research Network Presented at the: 33rd NAPCRG Annual Meeting October 15-18, 2005 Quebec City, Quebec, Canada

37. Context • Primary Care: • ~½ a billion office visits annually • the medical home for most Americans • Malpractice claims = burden of serious harms and death from medical errors is substantial • Most studies of errors reported by physicians = important but limited lens

38. Setting • 10 family physician offices: • 5 private practices • 5 residency clinics • American Academy of Family Physician (AAFP) National Research Network • mix of rural, urban, and suburban, private and community practices

39. Asked to Report • “That should not have happened and that you don’t want to happen again” • Small or large, administrative or clinical • Could be events or processes that didn’t happen but should have happened

40. Results • 401 physicians and staff signed a consent form and/or participated in site training (86% of eligible) • Clinic physicians, NPs/PAs, residents, and staff reported 726 events, 717 with errors • Staff 384 (53%) • physicians 278 (38%) • residents 46 (6%) • NPs and PAs 18 (3%) • 935 total errors

41. Top Ten Errors (AAFP NRN)

42. Error Consequences (AAFP NRN)

43. Error Consequences (AAFP NRN)

44. Patient reports (AAFP NRN) • 6 reports of extended waiting • 2 reports of mistaken identity • 1 report each • unnecessary blood-draw • Prescriptions • poor vaccination documentation • unnecessary emergency room visits (unable to reach PCP) • inability to get laboratory tests due to lack of insurance • inappropriate comments by clinicians • clinician-induced fear (patient left without treatment) • credit card theft

45. Clinician and Staff reports (AAFP NRN) • 96% were process errors • Clinicians were significantly more likely to report • errors related to medications, laboratory investigations, and diagnostic imaging • Staff were significantly more likely to report • communication with patients and appointments.

46. Multiple errors • Multiple errors: • 4 reports contained four errors • 33 reports contained three errors • 183 cases two errors • 93 cascades • Chart completeness and availability; medications; appointments; laboratory; patient flow; and filing systems.

47. Consequences & harms • 706 reports had consequences or harms • No patient died • 3 patients required urgent care, were admitted to a hospital, or had to visit the emergency room • 4 patients suffered pain or injury • 10 patients’ health condition worsened • Most placed the patient at heightened risk of harm (49%), or made the patients, their families or their health clinicians upset (33%).

48. Seriousness • “Complex” patients more likely very/extremely serious harm (31% vs. 20%, p=0.013) • No difference in risk for patients with chronic conditions (29% vs. 21%, p=0.086) • No differences for patients familiar vs. unfamiliar

49. AAFP NRN Discussion • Chaotic busy days, healthcare team communication failures, and breakdowns in protocols or guidelines often leave patients vulnerable • “Complex” patients should raise concern of serious harms • Reporters have difficulty divorcing systematic errors from blame

50. AAFP NRN Discussion • Multiple errors and error-cascades are common • Patients either don’t see errors often, won’t report them —understanding errors from their perspective will require another approach