Medical Error

Methods in Reducing Medical ErrorsIntroduction

Stephen Stripe MD, FAAFPShirley Cole-Harding PhD

Vicki Michels PhD

Historical Prospective

• Nov. 1999 IOM Report, “To Err is Human”

– Called for;

• Research into causes and solutions

• Enhanced Reporting of Errors

• Increased Expectations for Performance

Historical Perspective:Agency for Healthcare Research and Quality

Probability of:

• Acquiring AIDS from single unit of blood

• All heads on 20 consecutive coin tosses

• Death airline accident

• Death general anesthesia

• Death MVA

• Preventable Hospital Deaths

Historical Perspective

• July 2006 IOM Report

– 1.5 million medication injuries/year

– $3.5 Billion in hospital costs/year

DEFINING ERRORS

• Adverse Error (AE)- “an injury that results from medical error”

• Preventable AE

• Potential AE – “near miss” or “close call”

• Serious error=Preventable + Potential AE

Tracking Errors

• Brennan et al. (1991)

– 30,121 charts reviewed, NYS 1984

– Results

• 3.7% with AE

–1% negligent care

–51.2% of those with AEs died.

• Risk Factors

–Age > 64

–High risk surgery

Tracking Errors

• Leape et al. (1991)

– Types of Error

• Operative =47.7%

• Non-operative=52.3%

–Medication related=19.4%

–Diagnostic mishap=8.1%

–Therapeutic mishap=7.5%

Tracking Errors

• Bates et al., ( 1995)– Chart review and self-report on medical and

surgical units– Results;

• 6.5% ADE(1.8% preventable)• 5.5% with potential ADE• Rate highest in ICU• 42% of preventable ADEs life threatening or

serious–56% ordering–24% administration

Tracking Errors

• Cognitive errors in malpractice suits

– state and federal courts U.S 8th Circuit Court of Appeals Region

– In 59% of the cases cognitive errors could be identified

(Stripe et al. 2006)

Tracking Errors

• Adverse Events (AE) Reporting

– Self-report 0.04%

– Computer monitoring 1.7%

– Query clinicians 0.6-4.7%

– Chart review 3.7-16.7%

– Query+chart review 6.5%

– Direct observation 17.7-100%

Methods in Reducing Medical ErrorsSystems Approaches


Vicki Michels PhD

Systems Approach

“Medical care relies on the integrated efforts of a complex network of people and support services.”

(Cosby & Crosskerry, 2003, p. 73)

• “Humans err. We’re made that way.”• “Errors are attributes of systems”• “Errors result from a confluence of causes”

(Weingart, 2006)

“We can’t change the human condition, but we can change the conditions under which humans work.” (Reason, 2000)

Systems Approach

“Recognizing that medical errors are the fault of systems and not of individuals, (QuIC, 2000)

the purpose of hearing from this panel was to identify how improving patient safety can be a health care system-wide endeavor. …Some common themes raised by this panel were: confidentiality and protection, human factors, organizational/cultural issues, reporting systems, use of technology, and training of providers.”

What defines a system?

– Setting• ED, hospital

– People• Physicians• Nurses• Pharmacists• Technicians• Administrators

– Support systems• Radiology, laboratory, e.g.

– Organization

(Cosby & Croskerry, 2003)

Systems

Error

People

Support systems

Setting

Administration

Overview of Systems Theory

• Sources of error

– System problems

• even if human error is a factor

– Inadequate infrastructure to support high-tech medical care

– Teamwork failure

– Inadequate information networks

– Equipment failure


Settings

Sources of problems• The ED

– Overloaded, understaffed– High-acuity– Rapid decision making– Need rapid interventions


Teamwork

Sources of problems• Segregation of medical personnel during

training• Hierarchies• Lack of cross-checking• Lack of communication/information sharing• Lack of task sharing• Lack of coordination


Support Systems

• Design flaws in medication delivery– Naming, packaging, labeling– Handwriting– Matching staffing with demand– Delivery systems

(Weingart, 2006)

Systems solutions

• Recognize latent (systems) error is a component of most errors

• Encourage reporting of error

• Promote teamwork

• Prevent medication errors

• Improve information technology

• Address equipment problems

• Consider human factors in equipment design


Systems solutions

• Simplify and standardize

• Reduce handoffs

• Use constraints and forcing functions

• Build in appropriate redundancy

• Improve access to information

• Adopt best practices

• Take care of the system

(Weingart, 2006)

A Systems Solution

Computerized Physician Order Entry• 55% reduction in errors in serious medication

errors

Specific benefits– Streamlines ordering– Information needed at hand– Dosage guidance available– Checks performed

(Bates, 2006)

A Systems Solution

Problems with this CPOE system• Lessons

– Systems must be modified in response to problems occurring on implementation

– Software alone is insufficient– Rapid introduction may cause problems– Must be implemented well– Must have proper decision support– Must be monitored– Changes must be made in response to problems

(Bates, 2006)

Methods in Reducing Medical ErrorsIndividual Approaches


Vicki Michels PhD

Individual Approaches

• Introduction

– Systems made up of individuals

– Individual decisions create medical error

– Providing education will reduce medical error

Individual Approach Theory

• Factors affecting decision making

• Cognitive processes

• Situational influences

• Personality traits


• Cognitive Processes – Development of Schemas

• Experience• Observations

– Benefits of Schemas • Efficiency

– Cost of Schemas• Biases


– Type of Schemas

• Heuristics

–Representative

»Probability of occurring

–Availability

»Recent exposure to similar case


– Biases created by schemas

• Confirmation bias

• Fundamental attribution error

• Recency effect

• Commission bias

• Ommission bias

• Gender biases(Crosskerry, 2002)


• Situational Factors– Loss of situational awareness– Personal situational factors

• Illness• Medications• Stress• Alcohol or other substance use• Fatigue, hunger• Emotions

– External Pressures


• Personality Traits

– Antiauthority

– Macho

– Impulsive

– Invulnerability

– Resignation

Individual Solutions

• Improving meta-cognitive skills

– Educate about cognitive processes

– Educate about cognitive errors

– Develop strategies to prevent cognitive errors

(Crosskerry et al., 2000)

Individual Solutions

• Modified Aviation Prevention Model

– Stripe, Cole-Harding, & Michels

• Increase awareness of situational factors affecting decision making

• Increase awareness of personality on decision making

Assessment of Models

• Improving meta-cognitive skills– Curriculum for model well laid out

(Cosby & Croskerry, 2000;Croskerry, et al., 2000)– No systematic research to assess effectiveness

• Modified Aviation Prevention Model– Curriculum well laid out – Pilot study showed a 40% decrease in error for

family medicine residents who received Modified Aviation Prevention Training.• Only pre and post test, more research needed

Methods in Reducing Medical ErrorsIntegrated Model


Vicki Michels PhD

Integrated Models

Commercial Aviation Model

• Combined Systems and Cognitive Approach

– Checklists

– Scheduled maintaince

– Simulator training on a scheduled calendar for every flight officer

– Cognitive reviews on a scheduled calendar for every flight officer

Integrated Models

• Aviation Model Research Results

– Safest industry in the world involving high risk activity

– 0.232 incidents or accidents/100,000 flight hours

– Death in airline accident just greater than the odds of 20 consecutive coin tosses coming up all heads

Medical Model

Combined Systems and Cognitive Approach

• Checklists

• Standard routine orders; (pneumonia, acute coronary syndrome, etc.)

• Scheduled maintenance training

Medical Model

• EMR

• Prepackaged medications

• Cognitive review on a scheduled calendar for every physician, nurse, midlevel etc.

Medical Model

• Pilot study showed a 40% decrease in error for family medicine residents who received Modified Aviation Prevention Training.

• 55% with at least one systems approach

• What would the decrease in error be with a combined approach?

Medical Model

References

• Bates, D.W., The Patient Safety Imperitive, 2006.• Bates et al., JAMA 1995: 274;29-34 • Brennan et al. NEJM 1991: 324:370-6• Cosby, K.S. & Croskerry, P. Acad. Emerg. Med. 2003: 10; 69-78 • Croskerry, P. Acad. Emerg. Med. 2000; 7;1223-1231• Croskerry, P., Wears, R., & Binder, L., Acad. Emerg. Med.,

2000:7;11194-1200.• Leape et. Al. NEJM 1991: 324:377-84• Stripe, S., et al., JABFM, 2006• Weingart, S.N. The Patient Safety Imperitive, 2006.

Health & Medicine

Medical Error