Systems and Medical ErrorSystems and Medical Error

Ethan Cumbler M.D.Ethan Cumbler M.D.

University of Colorado University of Colorado HospitalHospital

20072007

Purpose of Patient Safety Purpose of Patient Safety CurriculumCurriculum

To discuss medical errors leading to adverse To discuss medical errors leading to adverse events in a systems based fashion. events in a systems based fashion.

To increase understanding of the errors that To increase understanding of the errors that occur in medicine on an individual level.occur in medicine on an individual level.

To educate on when and how to disclose medical To educate on when and how to disclose medical errors to patients.errors to patients.

To discuss medical error in the medico-legal To discuss medical error in the medico-legal context including steps which can reduce the context including steps which can reduce the chance of malpractice.chance of malpractice.

To create projects for risk reduction and error To create projects for risk reduction and error prevention.prevention.

How Has Internal Medicine How Has Internal Medicine Been Doing In Discussing Been Doing In Discussing

Medical Error?Medical Error? 2003 study found that only 1/3 of Internal 2003 study found that only 1/3 of Internal

medicine M+M conferences involved an medicine M+M conferences involved an adverse event and only 18% involved an adverse event and only 18% involved an error causing the adverse event.error causing the adverse event.

The error causing the adverse event was The error causing the adverse event was not discussed in ½ of cases.not discussed in ½ of cases.

Surgery M+Ms do a much better job of Surgery M+Ms do a much better job of discussing error and assigning discussing error and assigning responsibility.responsibility.

What is an Adverse Event?What is an Adverse Event?

Adverse EventAdverse Event

An unintentional, definable injury An unintentional, definable injury that was the result of medical that was the result of medical management and not a disease management and not a disease process.process.

What is a Medical Error ?What is a Medical Error ?

Medical ErrorMedical Error

Failure of a planned action to be Failure of a planned action to be completed as intended or the use of completed as intended or the use of a wrong plan to achieve an aima wrong plan to achieve an aim

BlameBlame

Errors leading to adverse events are rarely Errors leading to adverse events are rarely the expected outcome.the expected outcome.

Very few physicians want to be Very few physicians want to be responsible for an error.responsible for an error.

““Accident proneness theory”Accident proneness theory” Very rarely are errors due to the “bad Very rarely are errors due to the “bad

apple” physician. Thus weeding out the apple” physician. Thus weeding out the person responsible for an error does not person responsible for an error does not significantly reduce overall chance of significantly reduce overall chance of future errors. future errors.

How does Systems Thinking How does Systems Thinking Help?Help?

Systems ThinkingSystems Thinking

Errors in thinking have been recognized by the field Errors in thinking have been recognized by the field of cognitive psychology to be a product of normally of cognitive psychology to be a product of normally adaptive mental processes thus will occur in adaptive mental processes thus will occur in predictable circumstancespredictable circumstances

Recognize that errors which occur at the “sharp Recognize that errors which occur at the “sharp end” are a frequently influenced by pressures end” are a frequently influenced by pressures remote from the final accident.remote from the final accident.

Typically for an adverse event to occur as a result Typically for an adverse event to occur as a result of an error multiple mistakes need to have of an error multiple mistakes need to have happened at different levels of the system. Many happened at different levels of the system. Many of these are “latent errors” which have been of these are “latent errors” which have been present for some time.present for some time.

Good systems reduce the possibility of individual Good systems reduce the possibility of individual mistakes leading to harm “forced function”mistakes leading to harm “forced function”

RedundancyRedundancy

Remember that redundancy alone does not Remember that redundancy alone does not create safety. create safety.

In “An Experimental Study in Nurse-In “An Experimental Study in Nurse-Physician Relationships” 22 nurses received Physician Relationships” 22 nurses received a call from an unknown doctor with an order a call from an unknown doctor with an order to give 20mg of “Astrogen” immediately so to give 20mg of “Astrogen” immediately so it would have taken effect by his arrival. it would have taken effect by his arrival. The label on the bottle indicated 10mg was The label on the bottle indicated 10mg was the maximum dose. How many gave the the maximum dose. How many gave the drug?drug?

AnswerAnswer

21 out of the 22 nurses gave the 21 out of the 22 nurses gave the twice maximum dose as ordered.twice maximum dose as ordered.

Is that a product of the 1960s…. or Is that a product of the 1960s…. or does this still happen?does this still happen?

Example of Systems ProblemsExample of Systems Problems(Discovered after root cause analysis)(Discovered after root cause analysis)

Three Mile IslandThree Mile Island19791979 Maintenance crew lets Maintenance crew lets

water get into water get into instrument air system- instrument air system- Trips the turbines and Trips the turbines and feedwater to the feedwater to the reactor shuts down.reactor shuts down.

Emergency feedwater Emergency feedwater pumps come online but pumps come online but valves are closedvalves are closed

Lack of coolant fluid Lack of coolant fluid causes core temp and causes core temp and pressure to rise pressure to rise dramatically.dramatically.

Pressure pop-off valve Pressure pop-off valve opens but then sticks in opens but then sticks in the open position.the open position.

This exact error had This exact error had occurred two other times in occurred two other times in the past- never rectifiedthe past- never rectified

Valves were closed as a Valves were closed as a result of maintenance error result of maintenance error 2 days prior2 days prior

Warning light for the fact Warning light for the fact that the valves were closed that the valves were closed obscured by a maintenance obscured by a maintenance tag.tag.

Similar problem with stuck Similar problem with stuck open pop-off valve in open pop-off valve in another nuclear power plant another nuclear power plant 2 years prior but information 2 years prior but information was not disseminated to was not disseminated to other plants.other plants.

Three Mile IslandThree Mile Island

Operators fail to figure out Operators fail to figure out that the pop-off valve is that the pop-off valve is stuck open for 2 hours.stuck open for 2 hours.

Operators assumed that Operators assumed that the high temperature in the the high temperature in the core was due to a chronic core was due to a chronic leaking pipe which had leaking pipe which had been leading to high been leading to high temperature readings in temperature readings in this pipe for some time.this pipe for some time.

Radioactive water under Radioactive water under high pressure pours out high pressure pours out of pop-off valve opening of pop-off valve opening and into the basement.and into the basement.

The control panel was The control panel was poorly designed so that the poorly designed so that the light indicated whether the light indicated whether the open/close switch was open/close switch was commanded shut, but not commanded shut, but not the status of the actual the status of the actual valvevalve

Chronic deviation from Chronic deviation from proper function leads to proper function leads to incorrect assumptions incorrect assumptions when bigger malfunction is when bigger malfunction is occurringoccurring

Lessons For Medicine Learned Lessons For Medicine Learned From Three Mile Island DisasterFrom Three Mile Island Disaster Systems errors are frequently latent until Systems errors are frequently latent until

right sequence of events creates a perfect right sequence of events creates a perfect stormstorm

Human error and technology error have a dynamic Human error and technology error have a dynamic interactioninteraction

Errors are frequently not unique to a particular Errors are frequently not unique to a particular institution. Learning about preventing rare events institution. Learning about preventing rare events requires information sharingrequires information sharing

A culture of “normalizing” minor error occurrences A culture of “normalizing” minor error occurrences creates the groundwork for catastrophic errorcreates the groundwork for catastrophic error

Alarms which direct active human intervention are Alarms which direct active human intervention are helpful when dealing with rare events. Humans helpful when dealing with rare events. Humans are poorly designed to provide constant attention are poorly designed to provide constant attention to rare eventsto rare events

How Can We Analyze Medial How Can We Analyze Medial Error With A New Focus On Error With A New Focus On

Systems? Systems? Each Seminar we will start with a short Each Seminar we will start with a short

didactic lecture focused on one of the didactic lecture focused on one of the elements surrounding medical errorelements surrounding medical error

Seminar 1- SystemsSeminar 1- Systems Seminar 2- Individual Errors and HeuristicsSeminar 2- Individual Errors and Heuristics Seminar 3- Disclosure and Apology Seminar 3- Disclosure and Apology

How Can We Analyze Medial How Can We Analyze Medial Error With A New Focus On Error With A New Focus On

Systems?Systems?Modified Root Cause AnalysisModified Root Cause Analysis Prior to each seminar the faculty discussant will Prior to each seminar the faculty discussant will

prepare a case presentation of an actual medical prepare a case presentation of an actual medical error with information gathered from the patient, error with information gathered from the patient, chart, and interviews with all involved parties to chart, and interviews with all involved parties to facilitate the structured analysis.facilitate the structured analysis.

We will then discuss a modified root cause analysis of We will then discuss a modified root cause analysis of actual medical error using actual medical error using Systematic Analysis of a Systematic Analysis of a Medical Error form.Medical Error form.

After the RCA, small groups break-away sessions will After the RCA, small groups break-away sessions will explore the potential individual and systems solutions explore the potential individual and systems solutions to the problems identified in the RCA.to the problems identified in the RCA.

At least one solution will be explored as a simple At least one solution will be explored as a simple action step or potential future QI projectaction step or potential future QI project

See Sample Cases for examples of how a medical See Sample Cases for examples of how a medical error is processed through a modified root cause error is processed through a modified root cause analysis.analysis.

Case AnalysisCase AnalysisStep 1Step 1

Adverse event, Medical error, Adverse event, Medical error, CausationCausation

Was this an adverse event?Was this an adverse event? (An unintentional, definable injury that was the result of (An unintentional, definable injury that was the result of medical management and not a disease process.)medical management and not a disease process.)

Was there a medical error in the Was there a medical error in the case?case?(Failure of a planned action to be completed as intended or (Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim)the use of a wrong plan to achieve an aim)

Did the medical error lead to the Did the medical error lead to the adverse event?adverse event?(Requires causation)(Requires causation)

Case AnalysisCase AnalysisStep 2Step 2

Did system errors contribute?Did system errors contribute?Which types?Which types?

Communication- Communication- Incomplete information transfer or lack of Incomplete information transfer or lack of communication. For instance a patient who is allergic to morphine communication. For instance a patient who is allergic to morphine gets a dose of morphine by nocturnal cross-covering physician gets a dose of morphine by nocturnal cross-covering physician because allergies are not included in the information on check-outbecause allergies are not included in the information on check-out

Information Management- Information Management- Problems with the manner in Problems with the manner in which the organization stores, accesses, or transfers information. which the organization stores, accesses, or transfers information. For instance if clinic records are kept separate from hospitalization For instance if clinic records are kept separate from hospitalization records and a key piece of information is not accessible (such as records and a key piece of information is not accessible (such as resuscitation preferences) then this would be an information resuscitation preferences) then this would be an information management system problem.management system problem.

Technology- Technology- Problems with a piece of technology or the Problems with a piece of technology or the human-machine interface. An example would be a defibrillator human-machine interface. An example would be a defibrillator which required multiple steps, difficult to figure out without the which required multiple steps, difficult to figure out without the manual, to change from defibrillation mode to pacemaker mode.manual, to change from defibrillation mode to pacemaker mode.

Case AnalysisCase AnalysisStep 2Step 2

Did system errors contribute?Did system errors contribute?Which types?Which types?

Supervision-Supervision- If a less trained or skilled individual is being If a less trained or skilled individual is being required to perform tasks beyond their skill set with inadequate required to perform tasks beyond their skill set with inadequate measures in place for supervision. An example would be an intern measures in place for supervision. An example would be an intern performing first thoracentesis without supervision causing a PTX.performing first thoracentesis without supervision causing a PTX.

Workload-Workload- A systematic problem when the volume of tasks to A systematic problem when the volume of tasks to be performed overwhelms the resources available. System which be performed overwhelms the resources available. System which does not create mechanism to offload excessive work is accident does not create mechanism to offload excessive work is accident prone. Example would be missing thrombolytic window for a stroke prone. Example would be missing thrombolytic window for a stroke seen in the ED because number of other critical patients being seen seen in the ED because number of other critical patients being seen at same time.at same time.

Human Resources-Human Resources- When the system of staffing creates risk When the system of staffing creates risk for error. Example would be staffing model which maximizes for error. Example would be staffing model which maximizes handoffs is more prone to transitions errors.handoffs is more prone to transitions errors.

Case AnalysisCase AnalysisStep 3Step 3

List Individual Errors + TypeList Individual Errors + Type Knowledge basedKnowledge based- mistake from - mistake from

inadequate or incomplete inadequate or incomplete information or base of knowledge information or base of knowledge

Skill basedSkill based- performance error. Not - performance error. Not doing the action which was intended. doing the action which was intended. We think of this as a “slip” We think of this as a “slip”

Rule basedRule based- the incorrect - the incorrect application of the information. We application of the information. We think of this as a “Judgment failure” think of this as a “Judgment failure”

Case AnalysisCase AnalysisStep 4Step 4

List Heuristic Failures Leading List Heuristic Failures Leading to Individual Judgment Errorto Individual Judgment Error

Selected Heuristic Selected Heuristic FailuresFailures

□ □ Anchoring BiasAnchoring Bias □ □ Confirmation BiasConfirmation Bias: : □ □ Sunk Cost BiasSunk Cost Bias: : □ □ Availability BiasAvailability Bias:: □ □ Diagnosis MomentumDiagnosis Momentum: : □ □ Framing Effect:Framing Effect: □ □ Multiple Alternatives Multiple Alternatives

BiasBias: :

Selected Heuristic Selected Heuristic FailuresFailures

□ □ Triage CueingTriage Cueing: : □ □ Premature ClosurePremature Closure: : □ □ Base-rate neglectBase-rate neglect: : □ □ Representativeness Representativeness

RestraintRestraint:: □ □ Unpacking principalUnpacking principal: : □ □ Vertical line failure:Vertical line failure: □ □ Visceral bias:Visceral bias:

These Will Be Discussed In Detail In the Second Seminar

Case AnalysisCase AnalysisStep 5Step 5

What Level Harm Occurred As a Result What Level Harm Occurred As a Result of The Adverse Event?of The Adverse Event?

1- No harm, error identified prior to 1- No harm, error identified prior to affecting patientaffecting patient

2- Minor temporary harm2- Minor temporary harm 3- Minor permanent harm3- Minor permanent harm 4- Major temporary4- Major temporary 5- Major permanent5- Major permanent 6- Death6- Death

Case AnalysisCase AnalysisStep 6Step 6

What Would You Disclose?What Would You Disclose? Discuss what you would disclose Discuss what you would disclose

to the patient about the medical to the patient about the medical errorerror

Would there be an apology?Would there be an apology? How would this be approached?How would this be approached?

Disclosure will be discussed in detail in the third seminar

Case AnalysisCase AnalysisStep 6Step 6

What steps could be taken to What steps could be taken to reduce the probability of this error reduce the probability of this error

in the futurein the future Review concrete action steps to Review concrete action steps to

reduce chance of this medical error reduce chance of this medical error occurring in the future.occurring in the future.

Involvement of risk management is Involvement of risk management is helpful in creating systems changes helpful in creating systems changes which involve multiple disciplines.which involve multiple disciplines.

Back to GoalsBack to Goals

The goal of this series of seminars is to The goal of this series of seminars is to create suggestions for change in order to create suggestions for change in order to reduce errors but more than that it is to reduce errors but more than that it is to institute and maintain a change in the institute and maintain a change in the system.system.

The Hospitalist is uniquely positioned to The Hospitalist is uniquely positioned to make this a reality.make this a reality.

To learn about and use the hospitals error To learn about and use the hospitals error reporting system?reporting system?

Putting Theory Into PracticePutting Theory Into Practice

Begin Case Study in Systems ErrorBegin Case Study in Systems Error

ReferencesReferences

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2.2. C.K. Hofling et al. An Experimental Study in Nurse-Physician C.K. Hofling et al. An Experimental Study in Nurse-Physician Relationships. Journal of Nervous and Mental Disease 143; Relationships. Journal of Nervous and Mental Disease 143; 1966:171-80 (as quoted in The Lucifer Effect. Understanding 1966:171-80 (as quoted in The Lucifer Effect. Understanding how Good People turn Evil. Philip Zimbardo Random House how Good People turn Evil. Philip Zimbardo Random House New York 2007)New York 2007)

3.3. Blumenthal D, Ferris TG. Safety in the Academic Medical Blumenthal D, Ferris TG. Safety in the Academic Medical Center: Transforming Challenges Into Ingredients For Center: Transforming Challenges Into Ingredients For Improvement. Academic Medicine 2006;81:817-822Improvement. Academic Medicine 2006;81:817-822

4.4. Murayama KM, Derossis AM, DaRosa DA, Sherman HB, Fryer Murayama KM, Derossis AM, DaRosa DA, Sherman HB, Fryer JP. A Critical Evaluation of the Morbidity and Mortality JP. A Critical Evaluation of the Morbidity and Mortality Conference. Am J Surg 2002; 183:246-250Conference. Am J Surg 2002; 183:246-250

5.5. Spencer FC. Human Error in Hospitals and Industrial Spencer FC. Human Error in Hospitals and Industrial Accidents: Current Concepts. J Am Coll Surg 2000:191:410-Accidents: Current Concepts. J Am Coll Surg 2000:191:410-418418

ReferencesReferences

6.6. Buetow S, Elwyn G. Patient Safety and Patient Error. Buetow S, Elwyn G. Patient Safety and Patient Error. Lancet 2007;369:158-161Lancet 2007;369:158-161

7.7. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents Report on Adverse Events and Weissman JS. Residents Report on Adverse Events and Their Causes. Arch Intern Med 2005;165:2607-2613Their Causes. Arch Intern Med 2005;165:2607-2613

8.8. Patient Safety: Past, Present, and Future. Clinical Patient Safety: Past, Present, and Future. Clinical Orthopaedics and Related Research 2005;440:P242-250Orthopaedics and Related Research 2005;440:P242-250

9.9. James Reason. Human Error. Cambridge University Press. James Reason. Human Error. Cambridge University Press. Cambridge. 1990Cambridge. 1990