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Reducing Errors Reducing Errors Preventing InjuryPreventing Injury Saving Lives Saving Lives
Peggy G. Duke, M.D.
Associate Professor Emeritus,
Department of Anesthesiology
Division of Cardiothoracic Anesthesiology
Emory University School of Medicine
September 15, 2015
Developing A Culture of Safety Developing A Culture of Safety Easy to say, hard to doEasy to say, hard to do
At the most fundamental level reducing errors in medicine requires a shift in paradigm
Unwavering commitment and accountability
Organization’s leadership CEO, COO, CFO
Physician leadership
Nursing leadership
Departmental Chiefs
Frontline personnel
Physician role in changing the culturePhysician role in changing the culture
Acquiring new knowledge & skill sets
Assuming leadership roles in quality initiatives
Making practice changes based on new knowledge
Monitoring changes and revising when necessary
Working collaboratively with administrative, quality team departmental, nursing and frontline personnel
Helping develop evidence-based safety-driven protocols
In MedicineIn Medicine
Physicians lack of ownership of quality initiatives
In building and sustaining a culture of safety
Errors Occur Worldwide with Alarming FrequencyErrors Occur Worldwide with Alarming Frequency
Physicians, nurses, patients, all healthcare personnel, and hospital leaders need to
Grasp the scale of the problemAccept that errors are commonUnderstand the need to change to a culture that
views errors not as human failures but as opportunities to improve a faulty system
Institute of Medicine (IOM) 1999Institute of Medicine (IOM) 1999
1. 100,000 patients die in US hospitals annually as a result of medical errors
2. ~1 million excess injuries
3. 70% of the adverse events are likely preventable
4. Problem of accidental injury is serious
5. Cause is not careless people but faulty systems
6. Priority: redesign our systems to reduce errors
7. Patient safety must become a priorityTo Err is Human: Building a Safer Health SystemKohn LT, Corrigan JM, Donaldson MS, eds.
Washington, DC: National Academy Press; 1999.
Major Points
Annualized estimate of drug related errors Annualized estimate of drug related errors resulting in additional care in US resulting in additional care in US
(includes non-hospital care, office visits, etc.) (includes non-hospital care, office visits, etc.)
116 million extra visits to a physician
76 million additional prescriptions
17 million ER visits
8 million admissions to hospital
3 million admissions to long term care
199,000 additional deaths
Total cost $76.6 billion/year
Am J Health Syst Pharm. 1997 Mar 1; 54(5):554-8
2013 2013 Estimated patient harm in US hospitalsEstimated patient harm in US hospitals
Preventable
Deaths > 400,000/year
Serious harm > 4 - 8 million /year
Evidence-based estimate of patient harmIn US hospitalsJames; J Patient Safety 2013; 9: 122-128
Errors are underestimated Errors are underestimated
Many errors do not produce injury
Some errors are caught before reaching patient
Many patients are incredibly resilient
Sometimes we---patient & clinician-- get lucky
X
4-8 X
Medical errors occur Medical errors occur Worldwide Worldwide
With alarming frequencyWith alarming frequency In all settings In all settings
Cause serious harm or deathCause serious harm or death
Estimated that 10-20% of all health care encounters result in harm to patients
Basic Concepts of Human ErrorBasic Concepts of Human ErrorReason, JT Reason, JT
1990 Cambridge, England: 1990 Cambridge, England: Cambridge University Press Cambridge University Press
Errors inevitable part of being human
Errors are made by highly skilled, highly intelligent, conscientious professionals who hold themselves to very high standards
Error primarily results from latent errors caused by flaws in systems processes:
Design
Organization
Training
Management
Common Types of Human Errors Common Types of Human Errors Omission = failure to do
Missed diagnosis
Delayed evaluation
Failure to prescribe needed drug
Inadequate evaluation for respiratory depression
Commission = doing the wrong thing
Giving wrong drug
Operating on wrong side
Ordering wrong drug/wrong dose
Giving opioid to patient with undiagnosed respiratory depression
Communication
Failure to give vitally important information, i.e., allergy, last dose of antibiotic, difficult airway
FatigueDistractionsFear tospeak up
Lack of leadershipat CEO & other levelsUnderstaffingInadequate equipmentLack of resourcesLack of physician engagement
…Poorly designed processes…
Inconsistent expectations
InexperiencePoorly trained
Creating fear Gave wrong drugForgot crucial detail at handoffGave wrong bloodForgot to do diabetic foot , eye exam
Inadequate monitoring for respiratory depression
Incorporate proven safety Incorporate proven safety principlesprinciples
Train staff Principles of human error
Quality improvement techniques & approaches
Practice evidence-based or evidence-informed medicine
Harness the use of forcing functionse.g., e-prescribing with alerts and other computer assisted functions
Design team-based, protocol-driven approachesEspecially important in highly complex environments
Incorporate proven safety Incorporate proven safety principlesprinciples Standardize
equipment, supplies, & processes
Establish interdisciplinary teams discuss safety issues & problems in work environmentUnderstand your work environment
where are the breakdowns, bottlenecks, dangers?Remove fear
everyone should feel safe to speak up when concerned Stop “blame the person” mentalitySystematically design safety into processes of care
Incorporate proven safety Incorporate proven safety principlesprinciples
Develop checklists for handoffsRead out loud, in order, check off as acknowledged
Develop surgery & procedural checklistsRead out loud, in order, check off as acknowledged
Identify and communicate critical situations with “Repeat Back to Verify” similar to airline safety instructions
RUNWAY SAFETY: A Best Practices Guideto Operations and Communications “Do not acknowledge the ATC instructions or clearances by using your call sign and saying “Roger” or “Wilco” –
Instead read back the entire instruction or clearance including the runway designator and aircraft call sign.”
Managing Human ErrorsManaging Human Errors Blame the person (Traditional approach) AKA “Naming, blaming & shaming”
Systems Approach Assume faulty system design
Errors seen as caused by individuals
CarelessnessInattentionPoor motivationForgetfulnessPoor training
Errors seen as upstream system process design flawsLook for weak linksAdd barriers to reduce chance of human error
Accepts fact that one cannot change the human condition
Traditional approach has and will continue to fail to reduce human errors
"Insanity: doing the same thing over and over again and expecting different results.” Albert Einstein
Work in collaborative multidisciplinary teamsAnalyze the process Determine weak links Determine bottlenecks Determine high risk areas
Reduces errors & can lead to sustained changeStrong support & hard work can lead to a change in culture Culture of Safety >>>>>Just Culture
Management strategy Write more policiesPoster campaignsDisciplinary actionsRe-trainFire the individual
Support multidisciplinary teamsTeach human error theoryTeach systems approach
Change the conditions under which humans workDesign strategies/defenses to avoid/avert errors or mitigate their impact
Medical care: very complex chain of processes Aim to improve patients’ health and well being
Each link in chain can be associated with No problem Intermittent problems Variation Near misses (recognized or not recognized)
Safe throughput requires Knowing where the weak links, high risk areas and
dangers are Having systems’ barriers that reduce likelihood of errors
Healthcare is more complex than any other industryHealthcare is more complex than any other industry
Overwhelming ongoing increase in knowledge
Technology increasing in complexity
Procedures increasingly more complex
Less continuity of care in hospitals; multiple teams deliver care
More handoffs: each handoff increases likelihood of error
Multi-tasking Interruption-driven environment Increasingly older, high acuity patients with little reserve
Pressure to perform more, faster and with less support
One person providing care for multiple patients
Errors occur more commonlyErrors occur more commonly
When clinicians are inexperienced
New procedures are introduced
Patients at extremes of age—(perhaps not more errors, just less resilient )
Patients requiring complex care
Prolonged hospital stays
Highly technical areas, i.e., OR, ICU, ER
In highly technical surgical procedures, i.e., cardiac
surgery, neurosurgery, robotic surgery
You Don’t Have to Reinvent the WheelYou Don’t Have to Reinvent the Wheel
Much work already done
Start with already identified error prone areasMedication
Surgery
ICUs
Handoffs
Research: lots of data about how to begin
Checklists
Computerized forcing functions
Computerized physician order entry
Team developed protocols
How might we apply error reducing principles to How might we apply error reducing principles to an often overlooked but deadly probleman often overlooked but deadly problem
In-Hospital Cardiopulmonary Arrests (IHCA)
Specifically addressing a huge subset of IHCA
Postoperative Opioid Induced Respiratory Depression
In-Hospital Cardiopulmonary ArrestsIn-Hospital Cardiopulmonary Arrests(IHCA)(IHCA)
Up to 750,000 cardiopulmonary arrests annually in US hospitals
~ 80% of arrest victims do not survive to discharge
Studies show ~ 50% of those patients had been given opioids
Opioid induced respiratory depression
insidious
hard to diagnose using current technology
can lead to death or anoxic brain injury
occurs in very healthy patients
Overdyk, Guerra
American Nurse Today
6(1):November 2011, 26-31
Consider: The SubsetConsider: The SubsetPost-operative Opioid-Induced Respiratory Depression (POIRD) Post-operative Opioid-Induced Respiratory Depression (POIRD)
3rd most common in-patient safety related error
>50 % postoperative respiratory events thought to be caused by opioids
Each institution’s incidence may seem low--- BUT--- that is misleading
~48 million in-patient procedures in US
Absolute number of POIRD events is significant
Unexpected death or brain injury can occur in even healthiest patients
Worse outcomes for respiratory events that occur on general nursing floor
Likely related to intermittent monitoring
Undetected respiratory compromise
Additional IV opioids +/- sedatives
No significant change in patient outcome in past 40 years
POIRDPOIRD
2011 Our goal: “No Patient Shall Be Harmed By
Opioid-Induced Respiratory Depression” Dr. Stoelting, President
Anesthesia Patient Safety Foundation (APSF)
2015 Anesthesiology, Closed Claims Analysis: POIRD
Conclusion:
Multifactorial
88% occur within first 24 hours of surgery
Most events are preventable with improvements in
Assessment of sedation/consciousness level
Monitoring of oxygenation
Monitoring of ventilation
Early response & intervention
Closed Claims AnalysisClosed Claims Analysis March 2015 Anesthesiology Lee, CaplanMarch 2015 Anesthesiology Lee, Caplan
Medication factors
% Claims
Peripheral nerve blocks
0
Opioid given via > 1 modality
50%
Continuous opioid infusion
50%
Opioids + concurrent non-opioid sedating drug
33%
Multiple physicians ordering opioids +/- sedating drugs
33%
Excessive doses rarely the cause
%Claims Timing of event
88% Within 24 hours of surgery
13% Within 2 hours of D/C from PACU
% Claims Monitoring at time of event
50% No respiratory monitors
33% Non-telemetric SPO2
Example:Example:Tragic Error from 2015 Tragic Error from 2015 Closed Claims AnalysisClosed Claims Analysis
1st postop day: Obese, otherwise healthy 46 year old male Described as sleepy, slow to arouse, snoring loudly
SPO2 read 49% on room air
oxygen cannula replaced, SPO2 soon 93%
Described as being without complaints
24 minutes later found apneic
Full code called
Died few days later with anoxic brain injury
We Cannot Continue As UsualWe Cannot Continue As Usual
Large numbers of patients are still being harmed by postoperative opioids
POIRD often leads to death or anoxic brain injury
No change in patients’ outcomes for past 40 years
Monitoring SPO2 on general nursing floors is intermittent, if done at all
Monitoring respiratory rate alone is not adequate
Clinicians should be made awareClinicians should be made aware
SPO2 is a monitor of oxygenation not ventilation
SPO2 can be misleading when a patient is on supplemental oxygen
SPO2 monitors are known to have significant number of false alarms
ETCO2 is misleading and inadequate in non-intubated patients
Respiratory rate does not detect inadequate ventilation
Monitoring ventilation
Tidal volume, minute ventilation and respiratory rate would be ideal
What Safety Lessons Can Be Learned from the What Safety Lessons Can Be Learned from the Closed Claims Analysis DataClosed Claims Analysis Data
Patients on opioids post operatively are high risk for POIRDContinuously monitor oxygenation and ventilation
via telemetry or direct nurse call system
Use non-opioids analgesia when possible
peripheral nerve blocks
acetaminophen
ketorolacDevelop protocols that
Provide oversight by one physician-led team With same goals & knowledge of patient For ordering opioids For ordering sedating drugs
Do not allow opioids by more than one route i.e., if using PCA, do not give additional opioid IV push
Reducing Errors in MedicineReducing Errors in MedicineRequires Engaged PhysiciansRequires Engaged Physicians
Leaders, Champions, and Supporters Leaders, Champions, and Supporters
“Shake Up” the status quo
Look at the data
Understand human error theory
Understand your system processes
Work in collaborative, multidisciplinary teams
administration, nursing, physician, quality, etc.
Help develop & support processes, protocols that drive safety
“Walk the Talk”, i.e., do what you ask others to do
Physicians have the power to lead, change, and sustain a Culture of Safety
Culture of Safety Implies aCulture of Safety Implies a Just Culture Just Culture
Just Culture-------Trust is essential componentCollective understanding of where the line should be drawn between blameless and blameworthy actions.
Accepts that< 10% of errors are culpable> 90% of errors are systems’ flaws
Can be reported without concern for reprisal or sanctions
Reduces fear in reportingAllows learning from errors, near missesProvides data to improve processes
Data and Data AnalysisData and Data Analysis
Gather data about incidents and near-misses
Gather data about all cardiopulmonary arrests
Categorize & manage harm with severity assessment systems
Conduct Root Cause Analysis (RCA) to find sources of errors
Create opportunities for learning from errors and near misses
Establish Clinical Pathways, (evidence-based, standardized patient management)
Establish protocols for high risk situations
Building a Safe EnvironmentBuilding a Safe Environment
Accept as a given:One cannot change the human predisposition to make errors
Know the possibilities:One can change the conditions under which humans work and reduce errors in the delivery of healthcare
It is Also About You, Me, and It is Also About You, Me, and Those We LoveThose We Love
The urgency to decrease errors in healthcare should be readily recognized by anyone who:
is likely to require care sometime in the future
is aging
or both
That anyone is each one of us & our loved ones
Reducing Medical Errors A Marathon, Not a Sprint
24 hrs./day X 7 days/week X 52 weeks/year
ReferencesReferences1) Kohn, Corrigan, etal, eds, To Err is Human: Building a Safer Health System, Washington, DC: National Academy Press; 1999.
2) Am J Health Syst Pharm. 1997 Mar 1; 54(5):554-8
3) James; Evidence-based estimate of patient harm, In US hospitals, J Patient Safety 2013; 9: 122-128
4) Reason, JT , 1990 Cambridge, England:, Cambridge University Press
5) Anesthesiology 2010 POIRD-
6) Lee, Caplan, 2015 Anesthesiology, Postoperative Opioid-Induced Respiratory Depression, Closed Claims Analysis
7) Fecho K, Jackson F, Smith F, Overdyk FJ. In-hospital resuscitation: opioids and other factors influencing survival.
Ther Clin Risk Manag. 2009;5:961-968.
8) Brady WJ, Gurka KK, Mehring B, Peberdy MA, O’Connor RE; American Heart Associations’ Get with the Guidelines (formerly, NRCPR) Investigators. In-hospital cardiac arrest: impact of monitoring and witnessed event on patient survival and neurologic status at hospital discharge. Resuscitation. 2011;82(7):845-852.
9) HealthGrades. The Sixth Annual HealthGrades Patient Safety in American Hospitals Study. http://www.healthgrades.com/business/img/PatientSafetyInAmericanHospitalsStudy 2009.pdf. Accessed August 22, 2012.
10) Overdyk FJ. Postoperative opioids remain a serious patient safety threat. Anesthesiology. 2010;113(1):259-260.
11) Peberdy MA, Ornato JP, Larkin GL, et al. Survival from in-hospital cardiac arrest during nights and weekends. JAMA. 2008; 299(7):785-792.
12) HodgettsTJ,KenwardG,Vlackonikolis,I , etal .Incidence,location and reasons for avoidable in-hospital arrest in a district general hospital. Resuscitation. 2002;54(2):115-123.
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