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Patient Safety2013

Prevention of Medical Errors

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Why are we here?

• Concern over incidence of Medical Errors

• IOM Landmark Report (1999)– To Err is Human: Building a Safer

Healthcare System– Statistics

•44,000 – 98,000 Hospital deaths due to medical error

Impact of IOM Report

• Sparked a National Effort to:– change the culture of healthcare– change the systems of healthcare

• Culture change development:– Emphasis on compliance with standards– Good safety performance as a valued

organizational goal– Emphasis on continuous improvement

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Impact of IOM Report

• System Changes:• Move from Blame to Safety

– Shift from character and people related flaws to system and process flaws

– Discard the need to blame– Embrace the blameless exploration of

systems, processes and mechanisms

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Why are we here?

• To commit to paying greater attention to the problem

• We make a difference one at a time

• To evaluate current and new approaches

• To build better systems to reduce the incidence of error

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Why are we here?• 2001 FL Legislative response

– FS 456.013– Mandates 2 hour course for ALL

health care providers as part of licensure and renewal process

• Course shall include the study of:– root-cause analysis– error reduction– error prevention– patient safety

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Why are we here?

•FL BON Requirement –64B9-5.011–Continuing Education on Prevention of Medical Errors

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FL BON Requirement

• Subject Areas:– Factors that impact the occurrence

of medical errors– Recognizing error-prone situations– Processes to improve patient

outcomes– Responsibilities for reporting– Safety needs of special populations– Public education

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Definitions• Error (IOM):

– The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

• Adverse Event:– Injury caused by medical

management rather than underlying disease condition

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Definitions

•Medical Error–Preventable adverse events with our current state of medical knowledge

–Not defined as intentional act of wrongdoing

–Not all rise to level of medical malpractice or negligence

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Reporting Requirements

• Florida Law requires all licensed facilities to:– Have Internal Risk Management and

incident reporting system– Report Serious Adverse Events to:

•AHCA Agency for Health Care Administration

• See Sentinel Event Reported by year for guidelines

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Joint Commission

•National organization–Mission to improve the quality of care in healthcare institutions

–Provides Accredited status to healthcare facilities

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Joint Commission• Requires:

– Process in place to recognize sentinel events

– Credible root cause analysis (RCA)– Focus on systems not individuals– Risk reduction strategies– Internal corrective action plan

•Measure effectiveness of process•System improvements to reduce risk

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Root Cause Analysis

• Goal-directed, systematic process• uncovers basic factors that contribute to

medical error• Focuses primarily on systems and

processes and not individuals• Product of root cause analysis is an

action plan to reduce risk of similar future events

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Root Cause Analysis

• Gather facts

• Assemble team• Determine sequence of events• Identify causal factors• Select root causes• Take corrective action and follow-up plan

Joint Commission Sentinel Event Statistics

• Joint Commission Website– Go to Topics, Sentinel Event, Statistics– View Sentinel Event

•Summary•General Information – pg. 7•Root Causes – data unavailable – look at

last year•Trends Reported by Year

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Sentinel Events by Type Joint Commission Data

2004 - 2010• Top 6

– Wrong Pt., Wrong Site, Wrong Procedure– Delay In Treatment– Op/Post-Op Complications– Unintended Retention of Foreign Body– Suicide– Fall

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Sentinel Events by Setting Joint Commission Data

2004 - 2010

• Hospital (63.9%)• Psychiatric Hospital (11.4%)• Emergency Dept. (6.8%) • Psych unit in general hosp. (5.6%) • Behavioral health facility (3.9%)• Ambulatory Care (3.9%)

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Medication ErrorsPrevention

• Joint Commission abbreviations on the

• DO NOT USE list:• What is the leading root cause of

medication Errors??• Answer Poor communication

Joint Commission Do Not Use List

– U for Unit – write unit– IU for International Unit – write international

unit– QD, QOD – Write daily or every other day– Trailing zero (X.0 mg.) – write (X mg.)– Lack of leading zero (.X mg) - write (0.X

mg) – MS, MSO4, MgSO4 - write morphine sulfate,

magnesium sulfate 20

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Items Reviewed annually by Joint Commission

• The symbols “>” and “<”All abbreviations for drug namesApothecary unitsThe symbol “@”The abbreviation “cc”The abbreviation “μg”

ISMP: Tall Man Letters• Table 1. FDA Approved List of Established Drug Names with Tall Man Letters • acetoHEXAMIDE acetaZOLAMIDE • hydrALAZINE – hydrOXYzine • buPROPion busPIRone • medroxyPROGESTERone methylPREDNISolone methylTESTOSTERone • chlorproMAZINE – chlorproPAMIDE • clomiPHENE – clomiPRAMINE • cycloSPORINE – cycloSERINE • niCARdipine – NIFEdipine • DAUNOrubicin – DOXOrubicin • predniSONE – prednisoLONE • dimenhyDRINATE – diphenhydrAMINE • sulfADIAZINE – sulfiSOXAZOLE • DOBUTamine – DOPamine • TOLAZamide – TOLBUTamide • glipiZIDE – glyBURIDE • vinBLAStine – vinCRIStine

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ISMP

• Links to FDA Safety Alerts and Medication Safety Videos

– http://www.ismp.org– www.fda.gov/psn

And Much, Much More – A Great Resource!

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Collaborative Learning Activity

• Work in small groups of 5 – 6• Discuss specifically what you can do in

your life or practice setting to reduce medical errors

• Decide on 3 error reduction strategies to present to the group.

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Creating a Culture of Safety

• Understand human factors and system flaws

• Make safety everyone’s responsibility

• Report errors or near misses to decrease future error

• Actively seek improvement to process

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Creating a Culture of Safety• 6 major categories of negligence:

– Failure to follow standard of care– Failure to use equipment in proper,

responsible manner– Failure to communicate– Failure to document properly– Failure to accurately assess and monitor– Failure to act as an advocate for the

patient