Title: Reducing medical error and increasing patient safety
1Reducing medical error and increasing patient
safety
- Richard Smith
- Editor, BMJ
2What 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?
3A story
4How 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
5How 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.
6How 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
7How 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.
8Results 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.
9Types 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
10Types 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.
11Which 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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13How 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
14Why 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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16How 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)
17How to think of error?
- A systems failure
- This is the starting point for redesigning the
system and reducing error
18How 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.
19Building a safe healthcare system (from James
Reason)
- Principles
- Policies
- Procedures
- Practices
20Building 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
21Building 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
22Building 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
23Building 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
24Building 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
25Building 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
26Building 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
27James 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
28Conclusions
- 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
29Conclusions
- 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