Download Patient Safety

Patient Safety
2013
Prevention of
Medical Errors
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Why are we here?
• Concern over incidence of Medical
Errors
• IOM Landmark Report (1999)
–To Err is Human: Building a Safer
Healthcare System
–Statistics
•44,000 – 98,000 Hospital deaths due
to medical error
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Impact of IOM Report
• Sparked a National Effort to:
– change the culture of healthcare
– change the systems of healthcare
• Culture change development:
– Emphasis on compliance with standards
– Good safety performance as a valued
organizational goal
– Emphasis on continuous improvement
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Impact of IOM Report
• System Changes:
• Move from Blame to Safety
– Shift from character and people related flaws
to system and process flaws
– Discard the need to blame
– Embrace the blameless exploration of
systems, processes and mechanisms
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Why are we here?
• To commit to paying greater
attention to the problem
• We make a difference one at a
time
• To evaluate current and new
approaches
• To build better systems to reduce
the incidence of error
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Why are we here?
• 2001 FL Legislative response
–FS 456.013
–Mandates 2 hour course for ALL
health care providers as part of
licensure and renewal process
• Course shall include the study of:
–root-cause analysis
–error reduction
–error prevention
–patient safety
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Why are we here?
• FL BON Requirement
–64B9-5.011
–Continuing Education
on Prevention of
Medical Errors
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FL BON Requirement
• Subject Areas:
–Factors that impact the occurrence
of medical errors
–Recognizing error-prone situations
–Processes to improve patient
outcomes
–Responsibilities for reporting
–Safety needs of special populations
–Public education
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Definitions
• Error (IOM):
–The failure of a planned action to be
completed as intended or the use of
a wrong plan to achieve an aim
• Adverse Event:
–Injury caused by medical
management rather than underlying
disease condition
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Definitions
• Medical Error
–Preventable adverse events with
our current state of medical
knowledge
–Not defined as intentional act of
wrongdoing
–Not all rise to level of medical
malpractice or negligence
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Reporting Requirements
• Florida Law requires all licensed
facilities to:
–Have Internal Risk Management and
incident reporting system
–Report Serious Adverse Events to:
•AHCA Agency for Health Care
Administration
• See Sentinel Event Reported by year for
guidelines
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Joint Commission
• National organization
–Mission to improve the quality
of care in healthcare institutions
–Provides Accredited status to
healthcare facilities
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Joint Commission
• Requires:
–Process in place to recognize sentinel
events
–Credible root cause analysis (RCA)
–Focus on systems not individuals
–Risk reduction strategies
–Internal corrective action plan
•Measure effectiveness of process
•System improvements to reduce
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risk
Root Cause Analysis
• Goal-directed, systematic process
• uncovers basic factors that contribute to
medical error
• Focuses primarily on systems and
processes and not individuals
• Product of root cause analysis is an
action plan to reduce risk of similar
future events
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Root Cause Analysis
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Gather facts
Assemble team
Determine sequence of events
Identify causal factors
Select root causes
Take corrective action and followup plan
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Joint Commission
Sentinel Event Statistics
• Joint Commission Website
– Go to Topics, Sentinel Event, Statistics
– View Sentinel Event
• Summary
• General Information – pg. 7
• Root Causes – data unavailable – look at
last year
• Trends Reported by Year
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Sentinel Events by Type
Joint Commission Data
2004 - 2010
• Top 6
– Wrong Pt., Wrong Site, Wrong Procedure
– Delay In Treatment
– Op/Post-Op Complications
– Unintended Retention of Foreign Body
– Suicide
– Fall
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Sentinel Events by Setting
Joint Commission Data
2004 - 2010
• Hospital (63.9%)
• Psychiatric Hospital (11.4%)
• Emergency Dept. (6.8%)
• Psych unit in general hosp. (5.6%)
• Behavioral health facility (3.9%)
• Ambulatory Care (3.9%)
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Medication Errors
Prevention
• Joint Commission abbreviations
on the
• DO NOT USE list:
• What is the leading root cause of
medication Errors??
• Answer Poor communication
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Joint Commission
Do Not Use List
– U for Unit – write unit
– IU for International Unit – write
international unit
– QD, QOD – Write daily or every other day
– Trailing zero (X.0 mg.) – write (X mg.)
– Lack of leading zero (.X mg) - write (0.X
mg)
– MS, MSO4, MgSO4 - write morphine
sulfate, magnesium sulfate
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Items Reviewed annually by
Joint Commission
• The symbols “>” and “<”
All abbreviations for drug names
Apothecary units
The symbol “@”
The abbreviation “cc”
The abbreviation “μg”
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ISMP: Tall Man Letters
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Table 1. FDA Approved List of Established Drug Names with Tall Man Letters
acetoHEXAMIDE acetaZOLAMIDE
hydrALAZINE – hydrOXYzine
buPROPion busPIRone
medroxyPROGESTERone methylPREDNISolone methylTESTOSTERone
chlorproMAZINE – chlorproPAMIDE
clomiPHENE – clomiPRAMINE
cycloSPORINE – cycloSERINE
niCARdipine – NIFEdipine
DAUNOrubicin – DOXOrubicin
predniSONE – prednisoLONE
dimenhyDRINATE – diphenhydrAMINE
sulfADIAZINE – sulfiSOXAZOLE
DOBUTamine – DOPamine
TOLAZamide – TOLBUTamide
glipiZIDE – glyBURIDE
vinBLAStine – vinCRIStine
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ISMP
• Links to FDA Safety Alerts and
Medication Safety Videos
– http://www.ismp.org
– www.fda.gov/psn
And Much, Much More – A Great
Resource!
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Collaborative Learning
Activity
• Work in small groups of 5 – 6
• Discuss specifically what you can do in
your life or practice setting to reduce
medical errors
• Decide on 3 error reduction strategies
to present to the group.
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Creating a Culture of Safety
• Understand human factors and
system flaws
• Make safety everyone’s
responsibility
• Report errors or near misses to
decrease future error
• Actively seek improvement to
process
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Creating a Culture of Safety
• 6 major categories of negligence:
– Failure to follow standard of care
– Failure to use equipment in proper,
responsible manner
– Failure to communicate
– Failure to document properly
– Failure to accurately assess and monitor
– Failure to act as an advocate for the
patient
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