Case Examples

Case1: D-penicillamine VS Imipramine Case 2: Minoxidil VS Minidiab

Medical Errors
.. 27 2546

Facts
Health care has paid far less attention to error and safety than other industries Clinical research furnishes evidencebased practices that reduce complications of hospital care and improve patient safety.

Facts
Errors clearly play a causal role in the development of many adverse events Individual errors constitute just one of the many types of factors contributing to the occurrence of adverse patient outcomes

Facts
Pervasive medical culture of individual responsibility and blame stand in the way of efforts to make health care safer No amount of individual reprimand will change the fact that all providers will err from time to time

Facts
Most of the medical errors are systems related and not attributable to individual negligence or misconduct Focus on improving the systems of delivering care and not to blame individuals

Facts
Research shows the majority of medical errors are preventable Harvard Medical Practice Study review 1,133 medical records

70% of adverse events preventable 6% were potentially preventable 24% were not preventable

Facts
Medical research sponsored by the federal Agency for Healthcare Research and Quality (AHRQ) and the National Institute on Aging (NIA) Study of over 30,000 Medicare patients treated in the OPD setting during the period 1999-2000

Facts
As many as 1.9 million drug-related injuries a year because of medical errors or adverse drug reactions About 180,000 of these injuries are lifethreatening or fatal More than half are preventable

Facts

1,523 drug-related injuries or "adverse drug events.

Nearly 38% of the adverse drug events were serious, life-threatening, or fatal.
42% of the serious, life-threatening or fatal injuries were considered preventable

About 28% of all the drug injuries were considered preventable

Facts

Examples of more severe adverse drug events:

Falls with associated fractures Bleeds requiring transfusion Hypoglycemia, Deterioration of kidney function.

Most common categories associated with preventable ADE:

Cardiovascular drugs, diuretics, analgesics, hypoglycemic agents, and anticoagulants

Facts

Why the preventable adverse drug events occurred ?

58% Errors made when prescribing medications
Ordering the wrong drug or dose Not educating the patient adequately about the medicine Prescribing a medication for which there was a known interaction with another drug the patient was already taking

Facts

61% of preventable adverse drug events

Monitoring medications, such as inadequate laboratory monitoring Delayed response to symptoms of drug toxicity in the patient.

Over 20% of the preventable drug-related injuries

Failure of patients to adhere to medication instructions

Facts

The study published in the March 5, 2003, issue of the Journal of the American Medical Association.
"Computerized prescribing of medications may provide the potential to prevent the prescribing of drugs with known interactions, or to warn the prescriber to intensify monitoring of the patient. Efforts to enhance patient knowledge about their medication regimens are also essential to reducing the risks of drug-related injuries."

Errors versus adverse events

An error is an act or omission that leads to an unanticipated, undesirable outcome or to substantial potential for such an outcome. Act -active behavior (eg, prescribing an

inappropriate medication dose)

Omission-passive behavior (eg, forgetting to

check for allergies prior to prescribing or administering a medication).

Errors versus adverse events

Unanticipated
Situations where the outcome was not foreseen but deemed to be an acceptable risk in the decision-making process. Even when a decision turns out wrong, it would not be considered an error in this context

Errors versus adverse events

Medical errors :
The failure of a planned action to be completed as intended or The use of a wrong plan to achieve an aim.

Adverse events:
An injury caused by medical management rather than by the underlying disease or condition of the patient.

Errors versus adverse events

Some adverse events are not preventable and they reflect the risk associated with treatment (such as a lifethreatening allergic reaction to a drug when the patient had no known allergies to it)

Types of errors
Diagnostic Treatment Preventive Other

Diagnostic
Error or delay in diagnosis Failure to employ indicated tests Uses of outmoded test Failure to act on result of monitoring or testing

Therapy
Error in the performance of an operation, procedure, or test Error in administering the treatment Error in the dose or method of using a drug Avoidable delay in treatment or in responding to abnormal test Inappropriate (not indicated) care

Preventive
Failure to provide prophylactic treatment Inadequate monitoring or follow-up of treatment

Other
Failure of communication Equipment failure Other system failure

Scopes
Psychological principles Response to adverse events and serious errors

Types of cognitive behavior

Medical errors occur in the course of accomplishing one or more of the thousands of tasks of patient care Psychologists divide task-oriented behavior into two broad categories:

attentional schematic

Attentional behavior

Features:
Involves analysis, planning, oversight Generates sense of mental effort, intellectual satisfaction Quite error prone

Associated error type:

Mistakes Wrong rule applied Pattern recognition failure Knowledge- based mistakes Wrong judgment

Attentional behavior

Error-inducing conditions:
Inexperience relative to supervision Inadequate training Ambiguous or inconsistent key information Examples: Physician misinterprets signs of pulmonary embolus for pulmonary edema Physician prescribes antibiotic for sepsis which fails to cover common resistant bacteria

Schematic behavior

Features:
Automated or scripted Repetitive Usually requires oversight for best performance

Associated error type:

Slips more common than mistakes

Schematic behavior

Error-inducing conditions:
Stress, fatigue, distraction Inadequate oversight Insensitive system design or inflexible to changes in context

Examples:
Telemetry observer fails to notice frequent premature ventricular contractions Nurse receiving numerous intercom pages gives drug to wrong patient

Types of error

Two categories of error

Slips Mistakes

Slips
Inadvertent, unconscious lapses in expected behavior or inappropriate persistence of automaticity. Tend to affect schematic rather than attentional behaviors More frequent in sensory or emotional distractions, fatigue, and stress

Mistakes
Reflect incorrect choices. Typically involve insufficient knowledge, failure to correctly interpret available information Often divided into types of problems rule based and knowledge based Occur more frequently in insufficient experience or training

Responses to errors

Slips and mistakes are expected to occur from time to time Recognizing and developing strategies more likely to reduce their occurrence in the future Identifying the slip or mistake as a marker for system improvement than from finger pointing to blame and train a single person

Coping with mistakes and errors

Recommendations

Favor schematic behavior over attentional behavior

Checklists, standardized order sheets, and protocols reduce opportunities for slips.

Recommendations

Design schematic systems to be unambiguous, to anticipate all frequent and predictable occurrences, and to be flexible appropriate to the operator's judgment and experience
Protocol

Recommendations

Enhance attentional behavior through collaboration

ranging from informal sharing of opinions (curbside consultation) to formalized team meetings.

Recommendations

Assume that errors will occur and make their identification and prevention a positive cultural occurrence
Using the lessons of an error to reduce the likelihood of recurrence An objective, conceptual understanding of human error psychology can lead to systematic reductions in error frequency.

Potential system improvements

Use of information technology to eliminate reliance on handwriting for ordering medications and other treatment Avoidance of similar-sounding and look-alike names and packages of medication Standardization of treatment policies and protocols to avoid confusion and reliance on memory

Reporting adverse events and errors

Incident reporting
Passive surveillance Goal is to collect qualitative data from frontline providers of services Mandatory or voluntary Include adverse events or near misses

Incident-reporting systems

Established in a variety of nonmedical industries

commercial aviation and nuclear power

Characteristics
A focus on near misses Incentives for voluntary reporting An emphasis on error analysis An organizational culture supportive of quality improvement

Near misses

So few incident-reporting systems in health care function this way Targeting near misses offers several advantages
near misses occur 3 to 300 times more often than adverse events less likely to provoke guilt or other psychologic barriers to reporting analysis is less likely to be affected by hindsight bias (recognized tendency to judge care as inappropriate when it results in an adverse outcome)

Incident reporting in health care

3 categories:
Unexpected adverse outcomes Procedural breakdowns Catastrophic events

Examples of events reported to hospital incident-reporting systems

Adverse outcomes
Unexpected death or disability Inpatient falls or mishaps Institutionally acquired burns Institutionally acquired pressure sores

Examples of events reported to hospital incident-reporting systems

Procedural breakdowns
Errors or unexpected complications related to the administration of drugs or transfusion Discharges against medical advice Significant delays in diagnosis or diagnostic testing Breach of confidentiality

Examples of events reported to hospital incident-reporting systems

Catastrophic events
Performance of a procedure on the wrong body part (wrong-site surgery) Performance of a procedure on the wrong patient Infant abduction or discharge to wrong family Rape of a hospitalized patient Inpatient suicide

Limitations of incident reporting

Underreporting

Error analysis

Root cause analysis (RCA)

Retrospective approach Widely applied to investigate industrial accidents In 1997, JCAHO mandated the use of RCA in the investigation of sentinel events in accredited hospitals

Root cause analysis

Root cause analysis has 2 stages

1. Detailed timeline of the events
Disclose chronology of events Chart review Interviews with involved personnel

2. Search for active and latent errors

Active error Latent error

Root cause analysis

Active failures refer to the errors and violations that occur at the point of direct contact between the humansystem interface
human refers to the patient and the system is the hospital or other health care delivery system

Root cause analysis

Latent errors :
The system design failures that contributed to these active failures or allowed them to cause harm to the patient

Summary

Improving patient safety incorporates two complementary approaches

1. Provides qualitative methods for anticipating errors, documenting critical incidents, and responding to them in a blame-free and structured manner 2. Applying the results of quantitative clinical research to reduce some of the common hazards of hospitalization

Patient safety practice

Any healthcare structure or process that reduces the probability of adverse events resulting from exposure to the healthcare system across a range of diseases and procedures

Resources

To Err is human (online book from IOM)

http://books.nap.edu/books/0309068371/html/index. html

Quality and safety in health care

http://qhc.bmjjournals.com/

New England Journal of Medicine

www.nejm.org search for patient safety issue

Joint Commission on Accreditation of Healthcare Organizations

http://www.jcaho.org/

Resources

Agency for healthcare research and quality

http://www.ahrq.gov/

Institute of Medicine
http://www4.nationalacademies.org/iom/iomhome.nsf

National patient safety foundation

http://www.npsf.org/

Patient safety institute

http://www.ptsafety.org/