Medical errors why how
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Transcript of Medical errors why how
OPINION POLL
In today’s world .. Doctor’s have become more negligent! They do “anything”
Expectations of patients are rising and difficult to meet.
I am hearing more medical blunders than before.
I know one doctor who is really good and trustworthy.
Dr Nikhil D DatarMD DNB FCPS FICOG LLB DGO DHA Consultant Gynaecologist Nanawati Hospital & HindujaHealthcare
Founder President : Patient Safety Alliance
MEDICATION ERROR : WHY? HOW?
Harvard medical practice study
Dr Lucian Leap
Retrospective study of 30000 records. Incidence of adverse Events 3.7%
Inferences:
• 50% of these AE are preventable.
• Only 1% could fulfill the criteria of negligence
• The majority of them were not individual
failures but the system failures. It was a defective
system which was just waiting to fail.
Leap etal Obstet Gynecol Clin N Am 35 (2008) 1–10
THE RESPONSE
“The magnitude of this harm can be equated to two jumbo jets crashing every three days in the US”
New York state medical council stated that they are happy to note that only few doctors are negligent.
MEDICATION ERRORS IN US HOSPITALS
Adverse events related to medication :6.5 per 100 admissions.
Errors at two stages : ordering stage and administering stage
(Bates etal Journal of American Medical Association 1995,274:29‐34)
INTERNATIONAL DATA
Study No of Hospital Admissions
Adverse events (%)
United states (Utah‐Colorado study)
14565 5.4%
Australia (Quality in Australian Health care study)
14179 16.6%
United Kingdom 1014 11.7%
Denmark 1097 9%
WHO Executive board 109th session Dec 2001
DEATHS & DISABILITY
Australia:
Medical errors resulting into unnecessary deaths: 18000/ per year
Disability : 50000 / per year
(Weingart SN etal BMJ 2000, 320(7237):774‐777)
United states:
Deaths 44000‐ 98000/ per year
Injuries 1000000 / per year
(Kohn” To err is human” National Academy press 1999
COSTS
Cost of additional hospitalization, treating hospital acquired infection, loss on income, diability, medical expenses and cost of lititgation is estimated between 6 billion – 29 billion USD per year
( CMO‐“An organization with a memory. Report of an expert group on learning from adverse events in the NHS “ London Dept of Health UK 1999)
INDIAN SCENARIO
The probability of patients being harmed in developing world is higher than in industrialized nations.
It is estimated that the risk of HCAI is up to 20 times higher than in industrialised countries and is approx 15‐30% in acute care.
In the area of medication safety, 77% of all reported cases of counterfeit and substandard drugs are from developing countries. At least 50% of medical equipment is unusable or only partly usable‐ resulting into patient harm
(Report by National consultation workshop on patient safety by Ministry of Health & Family welfare Govt of India)
“Many people in the healthcare profession and
in the general public still believe that mistakes in
medical care are episodes of individual failure
and that most errors occur as a result of
someone not doing his or her job.”
‐‐‐Don Burwick (Achieving safe and reliable health care)
1991, Harvard medical practice study
1999, IOM :” To err is human”
IMPORTANT CONCEPTS
Adverse event is an injury related to medical management in contrast to a complication of disease.
Error is defined as “the failure of a planned action to be completed as intended (i.e. Error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning)”
Near miss” or “close call” is a serious error or mishap that has the potential to cause adverse event, but fails to do so by chance or because it was intercepted.
Hazard is any threat to safety
http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf
WHO MEMBER STATES PASS A RESOLUTION ON
PATIENT SAFETY
To reduce harm and suffering of patients and families
Economic benefits of improving patient safety
(WHO Patient safety Curriculum guide , 2009 : 81)
At the World Alliance for Patient Safety
MEDICINE IS COMPLEX
Harvard Venuguard query:
250 primary problems+ 900 secondary problems+300 medicines+ 100 diagnostic tests+40 procedures
In ICU settings , 179 procedures per day .. Which can prove dangerous.
MEDICINE IS POTENT
MEDICINE IS DE-PERSONALIZED
HOW RELIABLE IS HEALTH CARE?
1000010010 1000 1million 10million100000
hazardous Ultra-safe
Bungee jumping
Mountainclimbing
Chemical manufacturing
Scheduled airlines
European rail
Nuclear power
health
WITH SIR JAMES REASON
57 per 100000 deaths happen due to unintended injuries..It is the 9th cause of mortality in the world.
“SWISS CHEESE” MODEL OF ERRORS
Sir James Reason
Harm
Human/individual
factors
System/ organizational
factors
Circumstances/
Patient factor
RICHIE WILLIAMS
Great Armond street hospital is a reputed children’s hospital
Dr Dermot Murphy was a reputed hematologist
Dr John Lee was a specialist registrar in paediatric anaesthesia.
Alan Aitenhead Prof of Anaethesia Nottingham Univesrity:
“Death was a result of catalogue of mishaps & failings in the hospital systems than gross negligence.”
PHILOSOPHY OF ERRORS
Ignorance
Ineptitude
Samuel Gorovitz ( Journal of medicine and philosophy, 1970)
Situational Awareness
HUMAN ERRORS
Criminal actions
Intended actions: violations
Routine
Optimising
Necessary
Unintended actions:
Inadequate information: mistake
Attention failure: slip
Reliance on memory: lapse
FACTORS AFFECTING HUMAN BEHAVIOR
New procedure
Fatigue
Boredom
Overcrowding
Inadequate sleep
Inadequate food
Reliance on memory
WHY DOES THIS HAPPEN?
Is it because we do not work hard?
Is it because we do not concentrate?
Olny srmat poelpe can raed tihs. I cdnuolt blveiee taht I cluod uesdnatnrd waht I was rdanieg. Aoccdrnig to a rscheearch, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit a porbelm.
SITUATIONAL AWARENESS:
Nurse surgeon
anaesthetist
WHO STRATEGY
Learning from other industries
Educating and empowering patients
Encouraging error reporting
Evidence based medicine and uniformity of treatment
Preventing infection
Cost effectiveness
PATIENT SAFETY ALLIANCE
Empowering pateitns & supporting Health care professionals to prevent errors and harm during medical care.
THANK YOU
Change is a difficult process … even from worst to best.
The society accepts change in technology easily but not in ideology,