Title: Medication errors and patient safety
1Medication errors and patient safety
- Vic Vernenkar, D.O.
- Department of Surgery
- St. Barnabas Hospital
2Quality in Healthcare
- Begins with ensuring patient safety
3Patient safety
- Freedom from injury or illness resulting from the
processes of healthcare
4Healthcare errors
5Healthcare errors
- Failure to diagnose / incorrect diagnosis
- Failure to utilise or act on diagnostic tests
- Inappropriate use or outmoded diagnostic tests /
treatments - Failure to monitor or provide follow-up
- Wrong site surgery, medication errors
- Transfusion mistakes
6Healthcare errors
- Nosocomial infections
- Patients falls
- Pressure sores
- Phlebitis associated with intravenous lines
- Restraint related strangulation
- Preventable suicides
- Failure to provide prophylaxis
7How big is the problem?
- USA
- errors by HCWs affect about 3-4 patients
- mean of 7 ADEs
- gt7,000 ADE deaths / year
- 2 million nosocomial infections / year
- average ICU patient experiences almost 2 errors
per day - each year, 44,000 - 98,000 deaths due to medical
errors - annual cost of medical errors US29 billion
8Medication errors
- Prescribing errors
- Administration errors
- includes failure to monitor drug levels and side
effects of treatment
9Medication errors
- Rate of 3.99 per 1000 medication orders (Albany,
NY, USA) - a third had potential to cause adverse events
- Common factors
- failure to take account of declining
renal/hepatic function - failure to check for possible allergic responses
- using wrong drug name or means of administration
- miscalculation of dosage
- prescribing an unusual critical frequency of dose
Lesar et al. Factors related to medication
errors. JAMA 1997 277 312-7
10Why did it happen?
- Technology e.g. infusion pumps
- Many care-givers
- High acuity of illness / injury
- Environment prone to distraction
- Time-pressured, need to make quick decisions
- High volume, unpredictable patient load
11Key reasons
- Patients are more at risk than non-patients
- Medical interventions are, by their nature,
high-risk procedures - small error margins - Medicine remains an inexact, hands-on endeavour
12Errors are inevitable
.but most are preventable
13Facts
- Often it is the best people who make the worst
errors - About 90 of errors are not culpable
- But some people knowingly adopt behaviors more
likely to produce error - substance abuse, long
working hours
14Organisational accident model
James T Reason
15- Process review and change
16Whose job is it? - Risk Manager?
17Lessons from past
- Problems often formally recognised when there is
a major incident - Methodologies for organisational analysis not
well developed - Short-term corrective action not well sustained
- Problems in dealing with aftermath of service
failure - grievance of victims and their families
18Cycle of prevention
19Recommendations
- Leadership priority
- Clear organisational commitment to patient safety
(infrastructure and resources) - No-blame culture
20Culture of safety
- Integrated pattern of behaviour
- Underlying philosophy and values
- Continuos search to minimise hazards and patient
harm
21Culture of safety
- Acknowledges high risk, error prone nature
- Widespread shared acceptance of responsibility
for risk reduction - Open communication about safety concerns,
non-punitive environment - Reporting of errors and safety concerns
22Culture of safety
- Learns from errors
- Accountability for patient safety
- Organisational structure, processes, goals and
rewards aligned with improving patient safety
23Strategy 1 teams
- Implement known safe practices
- Design work so that it is easy to do it right and
hard to do it wrong - Reduce reliance on memory
- Less steps
- Constraints
- Protocols and checklists
- Clinical Pathways
- Care process models
24Teams - lessons from the navy
- Members monitor each others performance and
stepped in to to help out. TRUST was an implicit
part of this. - Giving and receiving feedback was norm for all
team members. Understanding each others role is
important part. - Communication was made real senders checked
their messages were received as intended.
25Teamwork and team leadership
- Good teams do not develop on their own
- organisational culture of welcoming openness and
monitoring changes that result - Good team leadership is essential
- development is vital across organisation
26Hospital team activities
- Improving information access
- hospital teams redesigned medication
administration records - Standardising and simplifying medication
procedures - teams worked on high risk and high
error-potential drugs - Restricting physical access to potentially lethal
drugs - chemotherapy drugs, concentrated KCl, NaCl
- Educating clinical staff about medications
- to assess knowledge deficiencies, drug knowledge,
awareness for potential for error
Silver et al. Reducing medication errors in
hospitals a peer review organisation collaboratio
n. J Qual Improvement 2000 26 332-40
27Strategy 2 education
- Recognise effect of fatigue on performance
- Education and training for safety
- Teamwork
- Reduce known sources of confusion
28Training and supervision
- Training in organisational aspects of care
- medical training focuses on diagnosis and
management of individuals - Training in skills of risk management
- understanding of inevitability of human error
- factors associated with errors, mistakes and near
misses - appropriate checking behaviour, safe handover
- team work
29Strategy 3 accountability
- Acknowledge error
- Apologise
- Provide remedial care
- Conduct root cause analysis
- Fix system or process problems
- Risk management system
- Sentinel event team
30Clinical incident reporting system
- Success depends on change in culture
- staff must be convinced of importance of patient
safety - board has to agree on no-blame culture
- systematic and strategic approach to risk
management - reporting system must produce reports that are
timely and informative
31Main Incident Page Reporting Person
32Risk Management System (RMS)
Fall Report
Fall Report
Fall Report
Fall Report
Sharp Report
Sharp Report
Sharp Report
Sharp Report
CEO/CMB
Reporting Nurse
Nurse Manager
Follow-up Doctor
Assist. Director Nursing
Sharp Report
CMB / Administrator
Sharp Report
Injured Staff
Supervisor / Manager
Sharp Report
Sharp Report
Sharp Report
Doctor Management
Dept Of Quality Management
Reporting Doctor
Fall Report
Head of Department/ Division Chairman
Medication Error Report
Medication Error Report
Medication Error Report
Infection Control (Sharp only)
Pharmacy Manager
Reporting Person
33Risk Management System
34Sentinel Event Team
- CEO
- CMB
- Administrator, Nursing
- Director, QM
- Administrator, Medical Board
35Sentinel Event Team
- Incident reporting, complaints
- Category I
- SET discussion
- Appoints team to investigate
36Root cause analysis
- Reviewing the process
- What happen?
- How did it happen?
- Why did it happen?
- What can we do differently?
37MOH requirement
- Report within 7 days of knowing
- Submit full report within 60 days
- De-identify
- Objective how can we improve
- what happen, how did it happen, why did it
happen, can we do differently?
38Impact
As evidence in support of the value of the
changes made to our processes, we observed no
further fatal ADEs.. John Rex et al.
Systematic root cause analysis of adverse drug
events in a tertiary referral hospital. J Qual
Improvement 2000 26 563-75
39- Key findings in IOM report
- Errors occur because of system failures
designing safer systems of care
To Err is Human.
Institute of Medicine, 2000.
Committee on Quality of Health Care in America.
40IOM report
- Avoid reliance on memory
- Use constraints or forcing functions
- Avoid reliance on vigilance
- Simplify key processes
- Standardise work processes
41Institutional practice
- Clinical risk management system
- Plan
- Process
- People
- Culture
- LEADERS