Would You Like Swiss Cheese on That?

Preventing Adverse Events in the Medication System

Objectives

• Review patient safety principles

• Learn from storytelling

• Discuss improvements to the medication use process

What is patient safety?• Patient safety is the identification and

control of hazards that could cause harm to patients

• Patient safety is the prevention of harm or injury to patients

What is patient safety?

• Is Patient safety a euphemism for medical error?– Not really - medical error is poorly defined and

often a euphemism for blaming an individual

• Patient safety is about providing a safe environment in which to practice.

While it is, of course, true that people make mistakes, it is not the whole truth, nor even the most important part of that truth.

James Reason

Multi-Causal Theory “Swiss Cheese” diagram (Reason, 1991)

What is the difference between focusing on the person and focusing on the system?

• Person approach– Focus on individuals

– Blaming individuals for forgetfulness, inattention, or carelessness, poor production

– Methods: poster campaigns, writing another procedure, disciplinary measures, threat of litigation, retraining, blaming and shaming

– Target: individuals

• System approach– Focus on the conditions and

environment in which individuals work

– Building fault tolerance in a system of work to reduce harm or mitigate its effects

– Methods: creating better system

– Targets: System (team, tasks, workplace, organization, physical environment)

A More Productive Approach

• People Don’t Come to Work to Hurt Someone or Make a Mistake

• Systems Issues > Individual’s Fault or Problem

• Common vulnerabilities can be found and fixed for EVERYONE, not just one person/place

Patient Safety Foundations

• Patient Safety is focused on the system and not the individual– We are not interested in: Who done it?

• Patient Safety is proactive with a focus to prevent patient harm

• We are interested in: What happened? How did it happen? Why did it happen? What are we going to do to prevent it from happening again? And, how are we going to measure whether or not our interventions are working?

Medication Safety

• Like other elements of safe practice it-– Does not happen by itself– We need to know what is wrong, or we can’t

fix it– It is not a “sprint” but a continuous never-

ending marathon– Requires a team commitment and good

communication by all

Communicating Events

• Report analysis

• Root causes analysis

• Storytelling and sharing

Click on video to play

How many medication errors have gone unnoticed?

Holes in the cheese

Contributing factors

What were the:

What would you do to fix?

• Low hanging fruit?

• Ideal processes?

• Ideal environment?

Process Improvements

• Verify Patient identifiers on Transcription

• Original order reviewed by administering nurse

• Missing medication retrieval process changes

• Timing of medication administration

• Pharmacy review of after hours activity

Future Improvements

• Computer generated MAR with standard administration times

• Bedside verification of medication administration with bar code technology

• 24 hour review of pharmacy activity

Remember:

• Patient safety is the identification and control of hazards that could cause harm to patients

• Common vulnerabilities can be found and fixed for EVERYONE, not just one person/place