Reducing medical error and increasing patient safetyRichard SmithEditor, BMJ

What I want to talk about

A storyHow common is error?Why does error happen?How should we think of error?How should we respond?

A story

How common is error?Harvard Medical Practice StudyReviewed medical charts of 30 121 patients admitted to 51 acute care hospitals in New York state in 1984In 3.7% an adverse event led to prolonged admission or produced disability at the time of discharge 69% of injuries were caused by errors

How common is medical error?Australian studyInvestigators reviewed the medical records of 14 179 admissions to 28 hospitals in New South Wales and South Australia in 1995.An adverse event occurred in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9%51% of adverse events were considered to have been preventable.

How common is medical error?The differences between the US and Australian results may reflect different methods or different ratesOther, smaller studies (including one from Britain) show similar orders of errorsThere are few studies from outpatients or primary care

How common is medical error?An evaluation of complications associated with medications among patients at 11 primary care sites in Boston.Of 2258 patients who had had drugs prescribed, 18% reported having had a drug related complication, such as gastrointestinal symptoms, sleep disturbance, or fatigue in the previous year.

Results of medical errorIn Australia medical error results in as many as 18 000 unnecessary deaths, and more than 50 000 patients become disabled each year. In the United States medical error results in at least 44 000 (and perhaps as many as 98 000) unnecessary deaths each year and 1 000 000 excess injuries.

Types of errorAbout half of the adverse events occurring among inpatients resulted from surgery.Next comeComplications from drug treatmenttherapeutic mishapsdiagnostic errors were the most common non-operative events. In the Australian study cognitive errors, such as making an

Types of error

Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.

Which patients are most at risk?Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgeryThose with complex conditionsThose in the emergency roomThose looked after by inexperienced doctorsOlder patients

How dangerous is health care?Less than one death per 100 000 encountersNuclear powerEuropean railroadsScheduled airlinesOne death in less than 100 000 but more than 1000 encountersDrivingChemical manufacturingMore than one death per 1000 encountersBungee jumpingMountain climbingHealth care

Why do errors happen?All humans make errors: indeed, the ability to make mistakes allows human beings to functionMost of medicine is complex and uncertainMost errors result from the system--inadequate training, long hours, ampoules that look the same, lack of checks, etcHealthcare has not tried to make itself safe

How to think of error?An individual failingOnly the minority of cases amount from negligence or misconduct; so its the wrong diagnosisIt will not solve the problem--it will probably in fact make it worse because it fails to address the problemDoctors will hide errorsMay destroy many doctors inadvertently (the second victim)

How to think of error?A systems failureThis is the starting point for redesigning the system and reducing error

How to respond? Tactics Reduce complexity Optimise information processing checklists, reminders, protocolsAutomate wiselyUse constraintsfor instance, with needle connections Mitigate the unwanted side effects of changewith training, for example.

Building a safe healthcare system (from James Reason)

PrinciplesPoliciesProceduresPractices

Building a safe healthcare system (from James Reason)PrinciplesSafety is everybodys businessTop management accepts setbacks and anticipates errorssafety issues are considered regularly at the highest levelPast events are reviewed and changes implemented

Building a safe healthcare system (from James Reason)PrinciplesAfter a mishap management concentrates on fixing the system not blaming the individualUnderstand that effective risk management depends on the collection, analysis, and dissemination of dataTop management is proactive in improving safety--seeks out error traps, eliminates error producing factors, brainstorms new scenarios of failure

Building a safe healthcare system (from James Reason)PoliciesSafety related information has direct access to the topRisk management is not an oublietteMeetings on safety are attended by staff from many levels and departmentsMessengers are rewarded not shotTop managers create a reporting culture and a just culture

Building a safe healthcare system (from James Reason)PoliciesReporting includes qualified indemnity, confidentiality, separation of data collection from disciplinary proceduresDisciplinary systems agree the difference between acceptable and unacceptable behaviour and involve peers

Building a safe healthcare system (from James Reason)Procedures-Training in the recognition and recovery of errorsFeedback on recurrent error patternsAn awareness that procedures cannot cover all circumstances; on the spot trainingProtocols written with those doing the jobProcedures must be intelligible, workable, available

Building a safe healthcare system (from James Reason)ProceduresClinical supervisors train their charges in the mental as well as the technical skills necessary for safe and effective performance

Building a safe healthcare system (from James Reason)PracticesRapid, useful, and intelligible feedback on lessons learnt and actions neededBottom up information listened to and acted onAnd when mishaps occurAcknowledge responsibilityApologiseConvince patients and victims that lessons learned will reduce chance of recurrence

James Reasons bottom lineFallibility is part of the human conditionWe cant change the human conditionWe can change the conditions under which people work

ConclusionsHuman beings will always make errorsErrors are common in medicine, killing tens of thousandsWe begin to know something about the epidemiology of error, but we need to know much moreNaming, blaming and shaming have no remedial value

ConclusionsWe need to design health care systems that put safety first (First, do no harm)We know a lot about how to do thatIts a long, never ending job