Patient Safety

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Patient Safety

• What is it?
• Why is it important?
• What are we doing?
• What is my part to play?

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Patient Safety What Is It?

• Error -- Failure of a planned action to
• be completed as intended or
• use of a wrong plan to achieve an aim

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Patient Safety What Is It

• Unsafe care can result from
• Fragmented health care system
• Faulty systems
• Increasing complexity
• Lack of awareness of extent of the problem
• Culture of individual focus and blame
• Lack of systemic view

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Patient Safety Why Is It Important?

• Institute of Medicine report sites studies
• Medical errors occur in 2.9 to 3.7 of hospital
  admissions.
• 8.8 to 13.6 of errors lead to death.
• Between 44,000 and 98,000 deaths occur each year
  in hospitals as a result of medical errors.

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Deaths Due to Preventable Adverse Events in
Hospitals

• Using lower number (44,000), 8th leading cause of
  death in the United States
• Exceeding
• Motor vehicle accidents (43,458)
• Breast Cancer (42,297)
• AIDS (16,516)

Institute of Medicine report
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Cost of Medical Errors

• 459 adverse events identified from 14,732
  randomly selected discharges at an estimated
  health care cost of 348 million. (Not including
  cost of loss income, disability, etc.)
• 265 of the 459 adverse events found to be
  preventable, which represents 159 million in
  health care cost.

Institute of Medicine report
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Cost of Medication Errors

• Most do not result in harm but those that do are
  costly.
• Recent study 2 of admissions have a
  preventable adverse drug event resulting in
• increased LOS of 4.6 days
• increased hospital cost of 4,700 / admission
• totals 2.8 million for 700-bed teaching hospital.

Institute of Medicine report
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Medications Administered in Allina

• More than 7 million doses of medications are
  administered per year in Allina Hospitals and
  Clinics.
• Is there an acceptable medication error rate?
• A 1 error rate would allow 70,000 errors.
• A 0.5 error rate would allow 35,000 errors.
• A 0.1 error rate would all 7,000 errors.
• Our goal is a fail-safe system that is free of
  errors

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This Doesnt Happen Here. Does it?
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This Doesnt Happen Here. Does it?
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Patient Safety What Are We Doing?

• Allina Hospitals and ClinicsPatient Safety
  Vision
• Achieve patient care environments free of
  accidental injury.

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Safe Delivery Principles

• Standard processes for doses, dose timing and
  dose scales
• Standardized prescription writing
• Limit number of different kinds of common
  equipment
• Implement physician order entry
• Implement decision support (eg drug dose
  drug-allergy)
• Unit dosing
• High risk IV supplied only by central pharmacy
• Written protocols for high risk medications
• No KCl on care units
• Pharmacist on rounds
• Patient information available at point of
  patient care
• Allergy wristbands
• Computer generated MARs
• Bar coding

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Swiss Cheese Model Defenses Against Errors
Hazards
Ideal
Reality
Errors
J. Reason
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Action Create a Safety Culture

• That . . .
• understands systems and how errors happen
• incorporates human factors research
• expects learning, not blame
• designs safe systems

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Action Allina Patient Medication Safety Task
Force

• Goals
• Increase awareness of unsafe systems.
• Implement mechanisms to allow learning from
  errors.
• Establish the principles of safe systems.
• Initiate and complete rapid cycle improvements in
  our systems.
• Improve reporting including near misses.

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Patient Safety -What Is My Part to Play?

• Practice Principles of Patient Safety
• Report
• Identify unsafe systems and take action to
  protect the patient