Reducing medical error and increasing patient safety

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Reducing medical error and increasing patient
safety

• Richard Smith
• Editor, BMJ

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What I want to talk about

• A story
• How common is error?
• Why does error happen?
• How should we think of error?
• How should we respond?

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A story
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How common is error?

• Harvard Medical Practice Study
• Reviewed medical charts of 30 121 patients
  admitted to 51 acute care hospitals in New York
  state in 1984
• In 3.7 an adverse event led to prolonged
  admission or produced disability at the time of
  discharge
• 69 of injuries were caused by errors

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How common is medical error?

• Australian study
• Investigators reviewed the medical records of 14
  179 admissions to 28 hospitals in New South Wales
  and South Australia in 1995.
• An adverse event occurred in 16.6 of admissions,
  resulting in permanent disability in 13.7 of
  patients and death in 4.9
• 51 of adverse events were considered to have
  been preventable.

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How common is medical error?

• The differences between the US and Australian
  results may reflect different methods or
  different rates
• Other, smaller studies (including one from
  Britain) show similar orders of errors
• There are few studies from outpatients or primary
  care

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How common is medical error?

• An evaluation of complications associated with
  medications among patients at 11 primary care
  sites in Boston.
• Of 2258 patients who had had drugs prescribed,
  18 reported having had a drug related
  complication, such as gastrointestinal symptoms,
  sleep disturbance, or fatigue in the previous
  year.

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Results of medical error

• In Australia medical error results in as many as
  18 000 unnecessary deaths, and more than 50 000
  patients become disabled each year.
• In the United States medical error results in at
  least 44 000 (and perhaps as many as 98 000)
  unnecessary deaths each year and 1 000 000 excess
  injuries.

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Types of error

• About half of the adverse events occurring among
  inpatients resulted from surgery.
• Next come
• Complications from drug treatment
• therapeutic mishaps
• diagnostic errors were the most common
  non-operative events. In the Australian study
  cognitive errors, such as making an

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Types of error

• Cognitive errors--such as incorrect diagnosis or
  choosing the wrong medication-- more likely to
  have been preventable and more likely to result
  in permanent disability than technical errors.

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Which patients are most at risk?

• Those undergoing cardiothoracic surgery, vascular
  surgery, or neurosurgery
• Those with complex conditions
• Those in the emergency room
• Those looked after by inexperienced doctors
• Older patients

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How dangerous is health care?

• Less than one death per 100 000 encounters
• Nuclear power
• European railroads
• Scheduled airlines
• One death in less than 100 000 but more than 1000
  encounters
• Driving
• Chemical manufacturing
• More than one death per 1000 encounters
• Bungee jumping
• Mountain climbing
• Health care

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Why do errors happen?

• All humans make errors indeed, the ability to
  make mistakes allows human beings to function
• Most of medicine is complex and uncertain
• Most errors result from the system--inadequate
  training, long hours, ampoules that look the
  same, lack of checks, etc
• Healthcare has not tried to make itself safe

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How to think of error?

• An individual failing
• Only the minority of cases amount from negligence
  or misconduct so its the wrong diagnosis
• It will not solve the problem--it will probably
  in fact make it worse because it fails to address
  the problem
• Doctors will hide errors
• May destroy many doctors inadvertently (the
  second victim)

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How to think of error?

• A systems failure
• This is the starting point for redesigning the
  system and reducing error

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How to respond? Tactics

• Reduce complexity
• Optimise information processing
• checklists, reminders, protocols
• Automate wisely
• Use constraints
• for instance, with needle connections
• Mitigate the unwanted side effects of change
• with training, for example.

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Building a safe healthcare system (from James
Reason)

• Principles
• Policies
• Procedures
• Practices

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Building a safe healthcare system (from James
Reason)

• Principles
• Safety is everybodys business
• Top management accepts setbacks and anticipates
  errors
• safety issues are considered regularly at the
  highest level
• Past events are reviewed and changes implemented

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Building a safe healthcare system (from James
Reason)

• Principles
• After a mishap management concentrates on fixing
  the system not blaming the individual
• Understand that effective risk management depends
  on the collection, analysis, and dissemination of
  data
• Top management is proactive in improving
  safety--seeks out error traps, eliminates error
  producing factors, brainstorms new scenarios of
  failure

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Building a safe healthcare system (from James
Reason)

• Policies
• Safety related information has direct access to
  the top
• Risk management is not an oubliette
• Meetings on safety are attended by staff from
  many levels and departments
• Messengers are rewarded not shot
• Top managers create a reporting culture and a
  just culture

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Building a safe healthcare system (from James
Reason)

• Policies
• Reporting includes qualified indemnity,
  confidentiality, separation of data collection
  from disciplinary procedures
• Disciplinary systems agree the difference between
  acceptable and unacceptable behaviour and involve
  peers

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Building a safe healthcare system (from James
Reason)

• Procedures
• Training in the recognition and recovery of
  errors
• Feedback on recurrent error patterns
• An awareness that procedures cannot cover all
  circumstances on the spot training
• Protocols written with those doing the job
• Procedures must be intelligible, workable,
  available

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Building a safe healthcare system (from James
Reason)

• Procedures
• Clinical supervisors train their charges in the
  mental as well as the technical skills necessary
  for safe and effective performance

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Building a safe healthcare system (from James
Reason)

• Practices
• Rapid, useful, and intelligible feedback on
  lessons learnt and actions needed
• Bottom up information listened to and acted on
• And when mishaps occur
• Acknowledge responsibility
• Apologise
• Convince patients and victims that lessons
  learned will reduce chance of recurrence

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James Reasons bottom line

• Fallibility is part of the human condition
• We cant change the human condition
• We can change the conditions under which people
  work

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Conclusions

• Human beings will always make errors
• Errors are common in medicine, killing tens of
  thousands
• We begin to know something about the epidemiology
  of error, but we need to know much more
• Naming, blaming and shaming have no remedial value

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Conclusions

• We need to design health care systems that put
  safety first (First, do no
  harm)
• We know a lot about how to do that
• Its a long, never ending job