Human error:

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Human error

• Recommendations

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The institute of medicine recommendations
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• A national center for patient safety to
• set national safety goals,
• track progress,
• fund research on error rates
• prevention strategies,
• serve as a clearinghouse of educational
  information and best practices.

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The institute of medicine recommendations
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• Mandatory reporting of errors that cause serious
  harm or death.
• While individuals would not be cited in these
  reports, institutions would be held accountable.

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The institute of medicine recommendations 1

• Voluntary reporting of errors that do not have
  serious consequences (or near-misses).
• The IOM recommended peer-review protections be
  extended to cover this level of reporting and
  that data be collected and analyzed solely to
  improve safety.

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The institute of medicine recommendations 1

• Increased attention by standards setting
  organizations within medicine, including groups
  that license and certify physicians and other
  health care providers (QA).
• The IOM called for periodic reexaminations to
  document the practitioners competence and
  knowledge and safety practices

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The institute of medicine recommendations

• Health insurance agencies should make patient
  safety a priority in their contractual decisions

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Error Identification

• Error identification, a well-defined process in
  many industries, is still in its infancy in
  medicine.

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• Solution for errors in medicine should focus on
  changes to the system and processes rather than
  punitive system for identifying and reporting
  preventable and potential adverse events

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Error Identification

• There are three methods of error identification
• Mandatory reporting
• Voluntary reporting
• Active surveillance systems

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Mandatory reporting

• In most organizations where mandatory reporting
  exists, a regulatory agency or governmental body
  mandates reporting of errors resulting in
  significant injury.
• These errors are discoverable by clinical audit
  (allowing enforcement), and they are the types of
  errors for which punitive action can be taken.
• This type of reporting satisfies the publics
  right to know

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Voluntary Reporting

• Voluntary error reporting systems are usually
  used to identify latent errors.
• In most organizations these systems are
  confidential (and sometime anonymous), and they
  often confer immunity from penalty.
• Non-punitive and confidential systems tend to
  have high compliance rate.

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Voluntary Reporting

• The aviation safety reporting system has received
  and saved more than 500,000 voluntary reports of
  near-misses.

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Active Surveillance

• Active surveillance is the identification of
  error through observation. This can be
• Direct observation while providing care
  (observers watching clinicians in action) or
• Indirect through chart review, or observation of
  error markers ( abnormal drug levels in serum as
  a medication dosage error marker)

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Success of incident reporting systems depends on

• Immunity (as far as practical)
• Confidentiality or data de-identification (making
  data untraceable to caregivers, patients,
  institutions, and so on)
• Independent outsourcing of report collection and
  analysis of peer experts
• Rapid meaningful feedback to reporters and all
  interested parties
• Ease of reporting
• Sustained leadership support.

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How should medicine evolve to reduce medical
error?

• Use Information technology to reduce medication
  error
• Reducing reliance on memory and vigilance
• Report errors for peer review
• Required autopsies for hospital deaths
• Mandatory MM conferences
• Use MM conferences to accomplish real QA and
  QI
• Push outcomes research efforts
• Sharing of data and improving communication
• Development of best practice guidelines based
  on medical evidence
• Eliminate the culture of blame
• Standardizing processes
• Improving physical feature of the workplace

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How should medicine evolve to reduce medical
error?

• Focus on error awareness (sentinel event alerts)
• Take a systemic view.
• Use errors as tools to analyze your design (root
  cause analysis).
• Be willing to redesign.
• Use simulations when possible.
• Automate data collection for error analysis.
• Perform structured evaluations to estimate human
  performance (performance monitoring).
• Compare current processes with standard ones
  (process auditing)
• Anticipate error through better coding.
• Supervise students during training

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Process auditing

• Process auditing is the systematic ongoing
  evaluation of facilities and procedures
• Process auditing involves anticipating where
  breakdown may occur and where barriers and
  defenses against mishap are weakest- the what
  it point of view

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Performance monitoring

• Performance monitoring is one technique to detect
  near- miss behavior before a patient has
  actually been injured

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Sentinel event

• A sentinel event is an unexpected occurrence
  involving death or serious physical or
  psychological injury, or the risk thereof.
  Serious injury specifically includes loss of limb
  or function.
• The phrase, "or the risk thereof" includes any
  process variation for which a recurrence would
  carry a significant chance of a serious adverse
  outcome.
• Such events are called "sentinel" because they
  signal the need for immediate investigation and
  response

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• "All sentinel events are the result of human
  errors that queue up in a particular sequence."

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Sentinel event watch

• When a sentinel event occurs in a health care
  organization, it is necessary that
• appropriate individuals within the organization
  be aware of the event
• investigate and understand the causes that
  underlie the event
• make changes in the organizations systems and
  processes to reduce the probability of such an
  event in the future.

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Sentinel event watch

• The leaders are responsible for
• establishing processes for the identification,
• reporting,
• analysis,
• prevention of sentinel events
• ensuring the consistent and effective
  implementation of a mechanism to accomplish these
  activities

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Sentinel event watch phases

• Identification of the errors that occur.
• Analysis of each error to determine the
  underlying factors -- the "root causes" -- that,
  if eliminated, could reduce the risk of similar
  errors in the future.
• Compilation of data about error frequency and
  type and the root causes of these errors.
• Dissemination of information about these errors
  and their root causes to permit health care
  organizations, where appropriate, to redesign
  their systems and processes to reduce the risk of
  future errors.
• Periodic assessment of the effectiveness of the
  efforts taken to reduce the risk of errors.

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• Insulin Common Risk Factors
• Lack of dose check systems
• Insulin and heparin vials kept in close proximity
  to each other on a nursing unit, leading to
  mix-ups
• Use of "U" as an abbreviation for "units" in
  orders (which can be confused with "O," resulting
  in a 10-fold overdose)
• Incorrect rates being programmed into an infusion
  pump

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• Suggested Strategies
• Establish a check system whereby one nurse
  prepares the dose and another nurse reviews it.
• Do not store insulin and heparin near each other.
  
• Spell out the word "units" instead of "U."
• Build in an independent check system for infusion
  pump rates and concentration settings.

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• "Errors must be accepted as evidence of systems
  flaws, not character flaws"
• (Leape, 1997)