Medical Students and Medical Errors

1
Medical Students and Medical Errors

• ICC 7001
• April 20, 2009
• Wendy Madigosky MD, MSPH
• Shelly Dierking, CEO Patient Safety Education
  Partnership

2
Objectives

• 1) Have an advanced understanding of the
  occurrence of medical error in the clinical
  environment
• 2) Have an appreciation for the personal impact
  of medical errors
• 3) Be aware of the student role in improving
  patient safety
• 4) Be familiar with local hospital efforts to
  reduce error and improve quality of care

3
Of course, we want patients to be safe!

• Implicit in providing quality health care is
  ensuring the care is safe.
• No health care provider sets out in the morning
  to see if they can make the care they provide
  more dangerous.
• However, the statistics suggest that despite the
  intrinsic role of safety in quality care, we fall
  short of the mark.

4

• How many of you have experienced a medical
  erroras a patient or family member?
• In your training thus far, how many of you have
  seen something that shouldnt happen again?

5
Working definitions
6
Epidemiology of Medical Errors
7
Adverse Events in Retrospective Studies

• New York State, 1984
• 3.7 of hospitalizations
• 69 caused by errors
• Colorado and Utah, 1992
• 2.9 of hospitalizations
• 6.6 mortality

8
Adverse Events inObservational Studies

• Chicago teaching hospital, 1997
• 45.8 patients on general surgical units
• 18 produced disability
• Israeli medical-surgical ICU, 1995
• 1.7 errors/patient/day

9
What does a 2-4 adverse event rate mean?

• 0.1 Rate
• 1 hour of unsafe drinking water every month
• 2 unsafe plane landings per day at OHare Airport
  in Chicago
• 16,000 pieces of mail lost every hour
• 22,000 checks deducted from the wrong bank
  account each hour
• 20,000 incorrect prescriptions every year
• 500 incorrect operations each week
• 50 babies dropped at birth every day
• Multiply by 20-40 to reflect a 2-4 error rate!

10
November 1999

• 33.6 million admissions to U.S. hospitals in 1997
• 44,000 - 98,000 deaths per year as a result of
  medical errors

11
Top Causes of Death in US 2006

• Heart disease 631,636
• Malignant neoplasm 559,888
• Cerebrovascular disease 137,119
• Chronic, lower respiratory disease 124,583
• All accidents 121,599
• Diabetes 72,449
• Alzheimers 72,432
• Influenza and pneumonia 56,326
• Nephritis/nephrosis 45,344
• Septicemia 34,234

www.cdc.gov/nchs
12
Deaths from Adverse Events

• More common than
• Breast Cancer
• Motor Vehicle Accidents
• AIDS
• 44,000-98,000 estimate does NOT include deaths
  from ambulatory sites (nursing homes,
  home-health, office-based practices)

13
What does this have to do with me?

• Medical errors are a significant cause of
  morbidity and mortality
• You are going to make mistakes, witness errors,
  and participate in unsafe care

14
Everyone makes mistakes, but

• Errors more common if
• Inexperienced providers
• New techniques used
• Adverse events more common if
• Patient age gt64
• Invasive procedures
• Complex illnesses
• Longer hospitalization

Weingart SN, Wilson RMcL, Gibberd BH.
Epidemiology of medical error. BMJ 320774-777.
15
Intern and Resident Mistakes

• 114 respondents (36 interns, 64 residents)
• Types of errors respondents admitted to
• Diagnosis (33)
• Prescribing and dosing (29)
• Evaluation and treatment (21)
• Outcomes
• 90 reported significant adverse patient
  outcomes, including death

Wu A, Folkman S, McPhee SJ, Lo B. Do House
Officers Learn From Their Mistakes? JAMA
19912652089-2094.
16
Types of Error Causes of Errors

• Diagnosis
• Evaluation
• Treatment
• Prescribing
• Procedures
• Communication

• Factual ignorance
• Faulty judgment
• Hesitation
• Breaks in concentration
• Inexperience
• Job overload
• Fatigue
• SYSTEM FLAWS

17
Basic Science of Medical Errors

• Medical knowledge
• Communication
• Teamwork
• Human factors engineering
• Cognitive science
• Quality Improvement

18
Demonstration Stroop Effect
Row 1
Row 2
Row 3
19
Now, State the Color of the Text as Fast as You
Can
Yellow
Green
Red
Blue
Row 1
Green
Red
Blue
Yellow
Row 2
Red
Blue
Yellow
Green
Row 3
20
Again, State the Color of the Text as Fast as
You Can
Red
Blue
Green
Yellow
Row 1
Yellow
Green
Red
Blue
Row 2
Blue
Yellow
Green
Red
Row 3
21
Tell the nursing student to attach the oxygen
mask and tubing to the green spigot
Patient Safety Correlation
For further info, see http//faculty.washington.ed
u/chudler/words.htmlseffect
J. Ridley Stroop (1935) Studies of
Interference in Serial Verbal Reactions. Journal
of Experimental Psychology, vol 18, 643-662
22
Weaker vs. Stronger Remedy
Communication Teamwork
Better
Make sure to use the correct color Adaptor!?
23
Human Factors Engineering and Your World

• Anesthesiology
• Design of alarms, monitors, and safety systems
• Emergency Medicine
• Design of decision-making tools and monitoring
• Surgery
• Design of hand tools and visualization devices
  (laparoscopy)

24
Video Demo

• Count the number of passes made between
  basketball players wearing white T-shirts
• Write down your answer (quietly not a group
  effort)
• At the end, I will ask for answers

25
Cognitive theory

• Cognition is how people reason and make decisions
• Providers may use deduction, induction or
  intuition to solve problems
• Novices lean toward deduction and exhaustive
  work-ups
• Experts have more knowledge and use logic,
  probability and especially intuition
• Coderre
  Med Ed 2003

26
Diagnostic Cognitive Errors/Solutions

• Aggregate bias
• Anchoring
• Availability bias
• Confirmation bias
• Diagnosis momentum
• Gamblers fallacy
• Suttons slip

• Develop insight
• Consider alternatives
• Metacognition
• Decrease reliance on memory
• Simulation
• Minimize time pressures

Croskerry Acad Med, Volume 78(8).August
2003.775780
27
Where do I learn more about this?

• Piecemeal within curriculum
• Self-guided study
• IHI Open School
• Free courses in patient safety, human factors
  engineering, quality improvement,
  teamwork/communication
• http//www.ihi.org/IHI/Programs/IHIOpenSchool/
• UCD Chapter now formed--if interested in helping
  to lead within AMC contact Dr. Madigosky
• AHRQ web MM www.webmm.ahrq.gov
• Web-based medical journal showcasing patient
  safety lessons drawn from actual cases involving
  medical errors
• 5 cases per month from medicine,
  surgery-anesthesia, OB/GYN, pediatrics,
  psychiatry
• Commentaries from experts

28
Bad Apple Theory

• Our systems are good and would be safe were it
  not for the actions of a few people who behave
  erratically.
• If an error occurs the task is to find out who
  did it and to take the necessary steps so they do
  not do it again.

S. Dekker, The Field Guide to Human Error
Investigations
29
New View of Human Error

• An error is a symptom of systemic factors in the
  environment which create the circumstances for an
  error to happen

S. Dekker, The Field Guide to Human Error
Investigations
30
Two views of human error

• Old
• Human error is a cause of accidents
• To explain failure you must seek failure
• You must find peoples inaccurate assessments,
  wrong decisions and bad judgments

• New
• Human error is a symptom of deeper problems
  inside a system
• To explain failure do not seek where people went
  wrong
• Instead, find how peoples assessments and
  actions made sense at the time, given the
  circumstances that surrounded them.

S. Dekker, The Field Guide to Human Error
Investigations
31
Our Medical Culture

• Taught in an authoritarian manner with a sense of
  absolute right/wrong
• Medicine is infallible we should be perfect
• There is always one right answer
• Confidence equals competence
• Error equals incompetence, negligence or laziness
• Error carries shame

Pilpel D, Schor R, Benbassat J. Barriers to
acceptance of medical error the case for a
teaching programme. Med Educ. 199832(1)3-7.
32
Awareness and Shame May be Largest Hurdles

• 1999 Survey at VA and Private Healthcare
  Organizations
• Only 27 Agreed that Errors were a Serious
  Problem
• 49 Ashamed by Error
• Blendon et al. (2003) in NEJM
• A majority of surveyed physicians thought that
  individual health care providers were more likely
  to be responsible for medical errors than
  hospitals

33
Medical Socialization

• The truth
• Baskin Robbins
• Discipline specific games
• Critical thinking

34
Typical Responses

• Denial
• Discounting
• Distancing
• Mizrahi T. Soc. Sci. Med, 1984. Vol 10 No 2 pp
  135-146.
• Guilt, fear, anger, embarrassment, humiliation,
  anxiety, depression, self-doubt, rumination about
  event, excessive concern, overwork, anguish
• Christensen JF et al. JGIM, 1992. Vol 7 pp424-431

35
Resident Responses

• Remorse
• Anger at selves
• Guilt
• Inadequacy
• Fear
• Psychological impact
• Wu A, et al. JAMA, April 24, 1991Vol. 265, No.
  16, Pg 2089-2094

36
Resident Coping Strategies

• Problem focused
• Acceptance of responsibility
• Consultation to understand the nature of the
  mistake
• Consultation to correct the mistake
• Planned problem solving (extra-training)

37
Resident Coping Strategies

• Emotion-focused
• Obtaining social support
• Disclosure to colleague, friend or spouse
• Disclosure to patient
• Reframing mistake

38
Resident Changes in Practice

• Constructive
• Increased information seeking
• Increased vigilance
• Improved self-pacing
• Improved communication
• Supervising others closely

39
Resident Changes in Practice

• Defensive
• Avoiding similar patients
• Being unwilling to discuss the error
• Ordering additional but unnecessary tests

40
Bottom Line

• To have constructive responses to medical errors
• Accept responsibility for the error
• Know that it may be emotionally stressful
• Disclose the error to others
• Use the error as an educational tool

41
Beyond Blame
42
Barriers to Patient Safety

• Medicine views errors as failings that deserve
• Blame and shame
• Corrective actions focusing on individuals
• Lack of awareness
• No blood no foul philosophy
• Many in health care ignore or downplay near
  misses, resulting in a missed learning opportunity

43
Should there be a blame free environment?

• Not necessarily
• In the VA, intentionally unsafe acts are excluded
  from safety
• Without individual accountability you cannot have
  safety or quality
• However, the system should be analyzed to look
  for problems before concluding that it was the
  fault of an individual

44
What is patient safety?

• Patient safety is the euphemism for medical
  error.
• Patient safety is the prevention of harm or
  injury to patients.
• But, does a lack of harm safety?
• Patient safety is the identification and control
  of things (i.e. hazards) that could cause harm to
  patients.
• Patient safety is that which allows you to pursue
  quality. In other words, without basic safety you
  cant have quality.

45
March 2001

• SAFE
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

46
Crossing the Quality Chasm

• Safety is a key dimension of quality
• Systems approach to safety improvement
• Simply trying harder will not work
• Stepwise correction of problems in the system is
  the key to success
• Overcome the culture of blame and shame
• Human error is to be expected!

Source Institute of Medicine 2001.
47
A Few Simple Rules for Health Care in the 21st
Century

• Current Approach
• Do no harm is an individual responsibility
• Information is a record
• Secrecy is necessary
• The system reacts to needs
• Professional autonomy drives variability

• New Approach
• Safety is a system property
• Knowledge is shared and information flows freely
• Transparency is necessary
• Needs are anticipated
• Decision-making is evidence-based

48
Person vs. System Approaches

• Person approach
• Focus on individuals
• Blaming individuals for forgetfulness,
  inattention, or carelessness, poor production
• Methods disciplinary measures, threat of
  litigation, retraining, blaming and shaming
• Target Individuals

• System approach
• Focus on the conditions under which individuals
  work
• Building defenses to avert errors/poor
  productivity or mitigate their effects
• Methods creating better systems
• Targets System (team, tasks, workplace,
  organization)

Reason J. Human error models and management. BMJ
2000320768-770.
49
Identifying System Issues

• Communication Issues
• Handoffs
• Standardization of communication
• Methods of documentation
• Communication between disciplines or across power
  gradients
• Education or Training Issues
• Equipment Issues
• Staffing Issues
• Fatigue or Scheduling Issues
• Policy Issues

50
The Swiss Cheese Model (Reason, 1991)
Production Pressures
Lack of Procedures
Attention Distractions
Zero fault tolerance
Deferred Maintenance
Mixed Messages
Punitive policies
Sporadic Training
Triggers
Clumsy Technology
Defenses
Team
Profession

• Policies/Procedures

Individual
Equipment
Environmental
Adverse Event
51
Systems ThinkingPrinciples and Concepts

• Interdependencies
• Structure drives behavior
• Cause effect are separated by time space
• Any change in a system has unintended consequences

52
Designing Systems for Safety

• Simplify processes
• Reduce hand-offs
• Make workplace user-friendly
• Reduce variation
• Standardize processes
• Reduce reliance on memory and vigilance
• Collaborate and improve communication
• Physicians, nurses, NPs, PAs, pharmacists...
• Patients and their families

53
Safe Care

• Culture promotes systemic change rather than
  individual blame
• Mechanisms to report near misses/errors
• Redundancy within system
• Well developed communication systems
• Re-engineering of work-flow and equipment

54
Screaming at a system is a very interesting
comment on the screamer, but tells us nothing at
all about the system.
Donald Berwick, MD, MPP
55
Why Do We Think the Systems Approach Will Work?

• Aviation Experience 400 reduction in aircraft
  accidents by utilization of root cause analyses
  and crew safety training.
• We are now using aviators to train health care
  workers in patient safety.

56
Why Do We Think the Systems Approach Will Work?

• Anesthesia Experience Over the last 20 years,
  anesthesia deaths have been reduced to 1/20th the
  prior rate. Interventions include
• Standardization of anesthesia machines
  re-engineering to prevent O2 cut-offs
• Reduced resident work hours
• End-tidal CO2 monitors
• Pulse oximetry

Gwande, A. Complications Metropolitan Books,
2002
57
The traditional view of medicine and medical
education on errors

• MMs
• Lets identify where things went wrong, what the
  right way should have been and talk about how we
  can avoid making this mistake again.
• Medical Education
• Focus on the individual learner. When mistakes
  happen you consider what the gaps in learning
  were, and how to remedy them.

58
The new view of errors from the hospital/health
system perspective

• The public has increasing attention on just how
  safe they are when they come for care
• Traditional methods of identifying and dealing
  with mistakes dont seem to work well
• Borrowing from other industries and from fields
  like human factors engineering
• Mandates to use new view methods by JCAHO and
  others

59
Right now both views of error co-exist in many
hospital and practice settings not necessarily
happily.
60
Hospitals are now mandated to do new view
analyses of adverse events

• Tools include
• Mandatory Adverse Event reporting
• Root Cause Analysis (RCA)
• Failure Modes and Effects Analysis (FMEA)
• Reporting of near-misses through voluntary
  reporting systems (e.g. Patient Safety Net)

61
UCH Safety/Quality Initiatives

• Hand Hygiene (100 compliance of foaming in/out)
• Hand Off Communication (during transitions)
• Medication Reconciliation (every visit and
  transitions)
• Critical Test Reporting (alerts to providers)
• Core Measures (pre-printed order sets)
• Pre-printed discharge instructions (AMI, CHF,
  Pneumonia, Surgical Site Infections)
• Signing, timing and dating all orders and
  progress notes
• Universal Protocol (time outs, HP
  available/reviewed)
• Central Line Infection Prevention (full barrier
  precautions, checklist completion)
• MET Medical Emergency Team (rapid response
  team)
• Disease specific inter-professional teams Stroke
  team, Diabetes etc.

Sue West, RN Assistant Vice Chancellor,
Professional Risk Management Director, UCH
Clinical Excellence Patient Safety Director,
Infection Control
62
UCH Safety Culture

• On-going improvement
• 2009 AHRQ Safety Culture survey
• Areas to work on
• Patient Safety Net reporting
• Staffing/workload concerns
• Punitive culture concerns
• Disruptive behavior issues
• Physician accountability.

UCH Insider Volume 2, Issue 21 Through April 27,
2009
63
Website for Additional Information on UCH Quality
Services

• http//iamaze.uch.ad.pvt/quality/index.htm

64
University of Colorado Hospital

• Professional Risk Management Department
• Sue West, Assistant Vice Chancellor
• To report a high level adverse event call
  [phone]
• Use Patient Safety Net at UCH for everything
  else. Icon on UCH desktop.
• Residents/fellows serve on the Risk Management
  Committee at UCH and on the board of the Schools
  Self-Insurance Trust.

65
The Childrens Hospital

• Patient Safety Leadership
• Teresa Fisher, Patient Safety Specialist
• Daniel Hyman, Chief Quality Officer
• Jeanne Crane, Risk Manager
• To report an adverse event
• QSRS (voluntary reporting system) 
• Icon on TCH intranet
• Residents involved with RCAs when they were
  involved in the care of patients with adverse
  outcome. All serious outcomes and JCAHO sentinel
  events get formal RCA.

66
VA Hospital

• Patient Safety Officer
• Jeriann Ascione
• To report an adverse event [phone]
• National voluntary reporting system.
• RCAs are done by ad hoc committees. Supportive of
  residents and fellows being involved but
  scheduling is a problem due to commitment over
  several weeks.

67
Denver Health

• Risk Management Department
• Dave Kvapil, Director
• To report an adverse event [phone]
• Risk Management staff do RCAs of all reportable
  adverse events and JCAHO sentinel events
• Follow up on Patient Safety Net reports of near
  misses as time permits
• No professionals-in-training involved in the RCA
  process

68
So what can I do as a medical student?

• Observe
• Ask
• Advocate
• Report
• Reflect

69
Take Home Points

• Lapses in safety include errors, adverse events
  and near misses
• Medical errors are frequent and significant
  threats to safe and quality health care
• A systems approach is more desirable than the
  blame/shame approach in improving safety
• The culture of medicine has led to barriers in
  improving patient safety but hospitals are
  working hard to implement safety/quality
  processes
• Medical students have a dual role to learn about
  safety/quality and to be a part of safety culture
  and improvement activities

70
Acknowledgements

• University of Missouri-Columbia
• Quality and Patient Safety Education Group
• John Gosbee, MD MS
• VA National Center for Patient Safety
• Patient Safety Curriculum Group

71
Fun Patient Safety Resource

• www.webmm.ahrq.gov
• Web-based medical journal showcasing patient
  safety lessons drawn from actual cases involving
  medical errors
• 5 cases per month from medicine,
  surgery-anesthesia, OB/GYN, pediatrics,
  psychiatry
• Commentaries from experts

72
Why Focus on the Near Miss?

• 10-100 times as frequent as adverse events
• People more willing to talk help evaluate
• Easier to highlight the system failures rather
  than individual failures
• Giant step towards prospective patient safety
  measures
• Experience is the best teacher, but if we wait
  for adverse events, who pays the tuition? The
  patient! - Jim Bagian (NCPS)

73
Culture of Safety and High Reliability
Organizations

• Safety is always on the agenda especially for
  top management
• Embrace information from near misses and hazard
  analysis
• Communication up and down the food chain
  regardless of hierarchy in organizational
  structure
• If you are not sure it is safe then it is not safe

74
System factors contributing to errors

• Equipment
• Environment
• Teamwork
• Staff
• Institutional Context
• Organization/Management
• Patient