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Reducing Medical Errors, Promoting Patient Safety Every Patient’s Right Everyone’s Responsibility Primum non nocere - Hippocrates Sharon Levine, MD Associate Executive Director Kaiser Permanente October 20-21, 2008 Beijing, China “Medicine used to be simple, effective and relatively safe - now it is complex, effective, and potentially dangerous” Sir Cyril Chantle “44,000-98,000 patients die each year in hospitals from medical error” May be as IOM report high as 195,000 deaths per year Health Grades 2004 Our Challenge: Preventing harm to patients from the care intended to help them 2 Accidental Deaths in the U.S. (National Safety Council, Harvard School of Public Health, 1999) 120,000 120,000 100,000 80,000 60,000 43,649 40,000 14,986 20,000 3,959 329 0 Medical Error Deaths MVA Deaths Fall Deaths Drowning Deaths Plane Deaths 3 How Do We Compare? DANGEROUS (>1/1000) 100,000 REGULATED ULTRA-SAFE (<1/100K) HealthCare Total lives lost per year Driving 10,000 1,000 Scheduled Airlines 100 Mountain Climbing Bungee Jumping 10 Chemical Manufacturing Chartered Flights European Railroads Nuclear Power 1 1 10 100 1,000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality 4 Top Patient Concerns About Hospital Stays Negative interaction of medications Getting the wrong medications Cost of treatment Procedural complications Having enough drug information Getting an infection during stay Suffering from pain 58% 61% 58% 56% 53% 50% 49% 5 Basis Of Error– Complexity Management System Staff Equipment/ Technology Environment Patient Powerful drugs Highly technical equipment/products Rapid decisions; time pressured Many care givers; multiple “handoffs” Task-based versus Systemsbased Limited resources Complex human factors High acuity illness / injuries Environment prone to distraction Variable patient volume; variable patient flow Requires more than “paying attention” and “trying hard” 6 Basis of Error - Complexity 80% medical error is system derived 95% mistakes— the good guys Identify and address the human factors Fix the system Understand the difference 7 “Culture of Safety” Awareness, understanding, and ownership of safety by all Constant vigilance to prevent error Learning from errors that do occur, and minimize chance of recurrence Teamwork, not hierarchy or autonomy Communication and hand-offs Non-punitive environment - encourage reporting of errors and near-misses Systems to mitigate “human factors” Memory capacity Mental processing Stressors: fatigue, emergencies 8 Behavior Biggest barrier to preventing errors – punishing people for making mistakes Human error--inadvertently doing other than what should have been done; slip, lapse, mistake - console At risk behavior - behavior where risk is not recognized, or is mistakenly believed to be justified - coach Reckless behavior - conscious disregard of a substantial and unjustifiable risk – remedial, then disciplinary action David Marx 9 “Culture of Systems” From patient-specific to systems view Indentifying patterns of error Standardization where appropriate: processes, procedures, checklists, standardized orders Care team accountability for error identification and elimination Expert team vs. team of experts: communication, simulation, attention to hand-offs 10 Drivers of Hospital Mortality and Morbidity Goals Drivers Focus Areas & Initiatives Infection Reduction No Needless Harm/Deaths Falls and pressure ulcers High Alert Medication Program Highly Reliable Surgical Teams Reduce Hospital Mortality and Morbidity EvidenceBased Care Appropriate Care Setting Disease-specific care: AMI, HF, PN, SCIP, CVA, glucose control Early goal-directed therapy Anticipating end of life: Palliative Care, Advance Directives Access to alternative care settings: SNF, HH, rehab 11 High Alert Medication Program High Alert Drug List Standardize: policies and procedures Education, training and retraining No-interruption zone, -wear Peer observations Measure, monitor, feedback Peer group: share learnings Leadership focus, oversight 12 MedRite Zone The Zone is an area marked out in front of the PYXIS to signify a “no interruption” area. Use of tape is a common zone indicator in hospitals such as in the OR and Pharmacy 13 No Interruption Wear (NIW) is the tool that helps minimize interruptions during medication administration Worn ONLY during the Medication administration process Allows the nurse to be “interrupted” at appropriate times 14 Percentage change from 1st mean (13.23 Jan to June ’06) to 2nd mean (26.0) June to April ’07: 97% From April ’07: Days since last event: 445 and counting 15 System Redesign for Safety: Highly Reliable Surgical Teams From “Art to Science” – Translating Evidence into Benefit Clinical Research Evidence Implementation Benefit REDESIGNING PROCESSES 16 System Redesign for Safety Clinical Research Evidence Implementation Check lists Safety Summit Teamwork Safety team in every OR Time-out Standardized orders Standardized orders Checklist for every role Benefit Observation/audit Debrief Simulation Training Report cards 17 Early Evidence of Benefit 40% reduction in surgical complications since 2001 From one surgery-related injury per 48 days (2003 to 2007) to one in 280 days (and counting) 2008 Significant and sustained improvement: in abx use/time/duration (97%); normothermia (95%); beta blocker use (97%) 18 Early Evidence: Surgical Care Improvement Program (SCIP) 100% Regional SCIP Performance Quarter 1 2008 90% 80% 70% SCIP Composite 60% 50% of Antibiotic Choice, Timing and Duration SCIP Abx Timing: 96% SCIP Abx Choice: 98% SCIP Abx Duration: 95% Hair Removal: 99% Normothermia: 92% Beta Blocker: 97% VTE composite: 94% 40% 19