1 Error in Medicine Joseph L. Halbach, M.D., M.P.H. Laurie Sullivan, Ph.D., CSW Department of Family...

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Error in MedicineJoseph L. Halbach, M.D., M.P.H.Laurie Sullivan, Ph.D., CSWDepartment of Family MedicineNew York Medical College andSaint Joseph’s Medical Center2003 – 2004

New York Medical College

Department of Family Medicine

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Jose Eric Martinez

The tragedy and suffering of an error

A reminder that errors result from a chain of events in a system

The fallibility of physiciansThe compassion that is required to

continue to practice The hope that we can do better



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Today’s Agenda

The Institute of Medicine (IOM)

Epidemiology of ErrorOur Role in Patient Safety



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The Medical Errors/Patient Safety Movement

Hilfiker article NEJM 1984 Mid 1990s incidents

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The Medical Errors/Patient Safety Movement

The Committee on the Quality of Health Care in America (1998)



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IOM Reports

To Err is Human: Building a Safer Health System

Crossing the Quality Chasm: A new Health Care system for the 21st Century

Health Professions Education: A Bridge to Quality

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Institutions

Institute for Healthcare Improvement (IHI) 1991

National Patient Safety Foundation 1996

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Institutions

Institute for Safe Medication Practices (ISMP)

Patient Safety Improvement Initiative of the Veterans Health Administration 1997

National Quality Forum (NQF)

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Agency for Healthcare Research and Quality – (AHRQ)

• July 2001 “Making Healthcare Safer: A Critical Analysis of Patient Safety Practices”

• October 2001 - $50 Million grant funding including a grant to the AAFP Policy Center to study outpatient medical errors.



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The Leapfrog Group

• Require hospitals to adopt computerized physician order entry.

• Steer patients to hospitals/doctors with high volume of high-risk procedures.

• Require ICUs to be staffed with critical care specialists.



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Medical Literature



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101520

253035

404550

5560

Year

Nu

mb

er

of

Art

icle

s

Articles on Medical Error/Patient Safety in Refereed Journals by year of publication (as of 4/15/02).

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To Err is Human

Establish a national focus on the issues of patient safety & medical error.

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To Err is Human

Identify & learn from errors through mandatory reporting efforts & encouragement of voluntary efforts.

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To Err is Human

Raise standards and expectations for improvement in safety.

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To Err is Human

Create safety systems inside health care organizations through the implementation of safe practices at the delivery level.

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IOM Definition of Error

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

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An Adverse Event

An injury caused by medical management rather than the underlying condition of the patient. An adverse event attributable to error is a “preventable adverse event.”

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Wu’s Definition

A Medical Error is “…a commission or omission with potentially negative consequences for the patient that would have been judged wrong by skilled and knowledgeable peers at the time it occurred, independent of whether there were any negative consequences.”

(Wu, 1997)

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Why Errors Occur

“The more complex the behavior, the less likely that it can be repeated successfully.”

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Why Errors Occur

Lack of StandardizationFailure to design with error in mindA medical culture that resists admitting

to error and so cannot work to prevent error.

(Schenkel S. 2000 Promoting safety and preventing medical error in emergency departments. Academic Emergency Medicine, Nov 7: 11, 1204-1222).

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Common Causes of Errors

Ignorance InexperienceFaulty judgment HesitationFatigue Job overloadBreaks in concentration

System flaws

(Wu AW, McPhee SJ, and Christensen JF. Mistakes in Medical Practice, Chapter 32 in Behavioral Medicine in Primary Care. 1997 Appleton and Lange, Stamford CT. Edited by MD Feldman and JF Christensen).

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Who Makes Errors

“The reality is that most errors are made by good people with good training, skills, and intentions who inadvertently commit errors despite their best efforts because of an unfortunate confluence of individual, workplace, communication, technologic, psychological, and organizational factors.”

(Annals of Emergency Medicine, July 2000, 59)

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About the Numbers

In-Patient

Out-Patient

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The Numbers

50:1 Ratio

Bates DW, O’Neil AC, Boyle D, et al. Potential identifiability and preventability of adverse events using information systems. J Am Med Inform Assoc. 1994; 1:404-411.

Jha AK, Kuperman GJ, Teich JM, et al., Identifying adverse drug events: development of a computer-based monitor and comparison with chart review and stimulated voluntary report. J. Am Med Inform Assoc. 1998; 5;305-314.

Cullen DJ, Bates DW, Small SD, et al. The incident reporting system does not detect adverse drug events: a problem for quality improvement . Jt Comm J Qual Improv. 1995; 21:541-548.

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The Numbers

44,000-98,000 Americans die in hospitals each year as the result of medical errors.

(To Err is Human, p. 44)

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The Studies

(1984) New York State hospital admissions/chart review

(1994) Colorado and Utah

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Worker Safety

6,000 Americans die from workplace injuries every year

1993, medication errors alone are estimated to have accounted for 7,000 deaths

(To Err is Human, p. 44)

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Preventable Adverse Events

8th leading cause of deathmotor vehicle accidents (43,

458)breast cancer (42,297) AIDS (16, 516)

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Costs

Estimated at between $37.6 & $50 billion for adverse events

$17-29 billion for PREVENTABLE adverse events

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Our Role in Patient Safety

What can you do to increase

patient safety in your practice?

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Prevention

Openly acknowledge error in Medicine

Analysis of systems rather than individuals

Vincent C. Risk, safety, and the dark side of quality. 1997: 314:1775-1776.

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Specific Suggestions

Plan a response to your next error.Become familiar with your

institution’s policies.Recognize your role as an Educator.

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What Patients Want

2. What happened?

3. That we are sorry

4. How are we going to prevent error in the future?

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Responding to Unanticipated Outcomes

CARE: Take Care of the Patient

PRESERVE: Preserve the Evidence

DOCUMENT: Document in the Medical Record

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REPORT: Complete Mandatory Reports if Required

NOTIFY: Notify Claims Department of Your Malpractice Carrier

DISCLOSE:The Initial Disclosure Discussion



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ANALYZE: Analyze Unanticipated Outcome to Prevent

Recurrence and /or Improve Outcome

(Root Cause Analysis)

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FOLLOW THROUGH: Subsequent Disclosure Discussions

HEAL: Heal the Health Care Team

(Norcal Risk Management)

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As an Educator

Recognize you are a role model.

Medical students and residents see errors made, make errors, do not see them discussed, and are greatly affected by medical errors.

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JCAHO National Patient Safety Goals 2003 and 2004

1. Improve Patient Identification2. Improve communication among caregivers3. Improve Safety of high-alert medications4. Eliminate wrong-site, wrong-patient, wrong-

procedure surgery5. Improve safety of Infusion Pumps6. Improve clinical alarm systems7. Reduce Healthcare – acquired infections

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The “New Look”

“The term…is being applied to a growing body of research on human and system performance aimed at learning how complex systems fail and how people contribute to safety.”

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From: Phillips DF

JAMA 1999; 281: 217



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The “New Look”

1. Emphasis on systems rather than people2. Nonpunitive approach3. Emphasis on the multifactorial nature of

error4. Assumption that errors will occur5. Emphasis on caregiver interactions6. Sharp end, blunt end

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From Wears RL and Leap LLAnn Emerg Med 1999; 34: 370-372



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“The paradox of modern quality improvement is that only by admitting and forgiving error can its rate be minimized.”

(D. Blumenthal, Editorial: Making medical errors into treasures. JAMA, 1994; 272:1867-8.)

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1 Error in Medicine Joseph L. Halbach, M.D., M.P.H. Laurie Sullivan, Ph.D., CSW Department of Family...

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