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Transcript of Saeid Eslami [email protected]. Errors and ADEs are costly Adverse Events in USA Hospitals: 80,000...
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Errors and ADEs are costlyAdverse Events in USA Hospitals:
80,000 people hospitalised/year
7,000 deaths/year.
50% of these errors definitely or possibly preventable
$22 billion, costs of preventable adverse events
(1999 USA Institute of Medicine Report)
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Errors and ADEs are costlyAt least 1.5 million preventable
ADEs occur each year in the US:
Hospital: 380,000-450,000. Ambulatory Care: 530,000 Long-term care: 800,000
Cost of ADE Non-preventable ADE: $2,595 Preventable ADE: $4,685
Bates DW et al . JAMA. 1997
خبر خوب، من موبایلمو پیدا
!کردم
خبر بد، رو !!ویبراتور بوده
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In Holland (2005): Each year 10,000 people receive wrong medication
and more than 3000 death each year because of errors.
In Australia:Medical error results in as many as 18 000
unnecessary deaths, and more than 50 000 patients become disabled each year.
AU$ 5 Billion (AUS)
Errors and ADEs are costly
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Medication Errorsnearly 1 of every 5 doses in the typical hospital and
skilled nursing facility.The percentage of errors rated potentially harmful was
7%, or more than 40 per day in a typical 300-patient facility.
The problem of defective medication administrations systems, although varied, is widespread.
Medication Errors Observed in 35 Health Care Facilities Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD, et al. (REPRINTED) ARCH INTERN MED/VOL 162, SEP 9, 2002 2002 American Medical Association
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Adverse Events -International information
Baker et al, Canada 2000Thomas et al, Utah Colorado
1992Wilson et al,* Australia, 1995Thomas et al, 2000, reworked
1995 Australian dataBrennan et al, Leape et al, New
York 1984Vincent et al, London 1999,2000Davis et al*, New Zealand 1998
AE’s Preventable7.5% 36%
2.9% --
16.6% 51%
10.6% --
3.7% --
10.8% 48%
12.9% 37%
* Slight to modest evidence of healthcare management causation = 2 out of 6 scale, other papers management causation more certain:- 4 out of 6 scale
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Source – The Philadelphia Inquirer
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The(US) National Burden of Systemic Errors in the Health Care
More than 3 fully occupied Jumbo jets of the Health Care Industry drop out of the sky every day ! (Adapted from Leape:
the Patient Safety Guru of USA)
And then there are other adverse Events!!
US H
ealthcare
In 2001 there were 4.3 millionambulatory visits for treating Adverse Drug Events Zhan et al 2005
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How Hazardous Is Health Care?How Hazardous Is Health Care?(Modified from Leape)(Modified from Leape)
1
10
100
1000
10000
100000
1 10 100 1000 10000 100000 1000000 10000000
DangerousDangerous
(>1/1000)(>1/1000)
RegulatedRegulated Ultra-Ultra-SafeSafe
(<1/100(<1/100K)K)
HealthCare
Bungee Jumping
Mountain Climbing
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
Numbers of encounter for each fatalityNumbers of encounter for each fatality
Tota
l li
ves
lost
per
year
Tota
l li
ves
lost
per
year
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………Patient safety defined as freedom from accidental injury due to medical care…..Institute of Medicine. To Err is Human. Building a safer Health System, Washington, National Academy Press: 1999
An adverse events: harm or injury caused by the management of a patients’ disease or condition by health care professionals rather than by the underlying disease or condition itself……The World Health Profession Alliance
Definitions:
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Definitions:Sentinel Event
An unexpected occurrence involving a death or serious physical or psychological injury or risk thereof. Serious injury specifically includes loss of limb or function.
Preventable Adverse EventCould/should not have happened (Error)
Non-Preventable Adverse EventCould not have been predicted or foreseen
Potential Adverse Event“Near miss” or “close call”, could have resulted in an
accident, injury or illness, but did not, either by chance or through timely intervention
Errorthe failure of a planned action to be completed as intendedthe use of a wrong plan to achieve an aim.
11
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Errors Types (another classification)
G and R Singh
Overusein 2001 top 50 medical and surgical procedures numbered 42 million. 7.5 million of these were unnecessary surgical procedures – causing about 40,000 deaths.
UnderuseMuch greater problem than Overuse. Patients failed to receive recommended care about 46% of the time. e.g. hypertension receives 65% of recommended care.
MisuseAbout 11% of the time patients receive care not recommended – leading to harm
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Medical Errors & Adverse Events
13
Medical ErrorsAE
Preventable AE
Non-preventable
NearMiss
Serious Medical Errors
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A, R & G Singh 2002
Advances in medical knowledge required to prevent
recurrence
Patient’s Encounter with Health Care System
No error occursIF
Unavoidable adverse event
occurs
OU
TC
OM
EA
CT
ION
R
QD
Opportunities for system redesign and improvement – commonly go
unnoticed
Beneficial outcome may occur
IF
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System redesign and improvement
required to prevent
recurrence
Patient’s Encounter with Health Care System
IFError occurs
Consequential
Preventable adverse event
occurs
IF
OU
TC
OM
EA
CT
ION
R
QD
A, R & G Singh 2002
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Opportunities for system redesign and improvement – commonly go
unnoticed
Patient’s Encounter with Health Care System
IFError occurs
Inconsequential on its own
Beneficial outcome may occur
IF
OU
TC
OM
EA
CT
ION
R
QD
A, R & G Singh 2002
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System redesign and improvement
required to prevent
recurrence
Patient’s Encounter with Health Care System
IFError occurs
IF
Inconsequential on its own
IF
Preventable adverse event
occurs
Undetected(may causecascade of
errors)
IF
OU
TC
OM
EA
CT
ION
R
QD
A, R & G Singh 2002
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System redesign and improvement
required to prevent
recurrence
Advances in medical knowledge required to prevent
recurrence
Opportunities for system redesign and improvement – commonly go
unnoticed
Patient’s Encounter with Health Care System
No error occursIF
Error occurs
IF
ConsequentialInconsequential on its own
IF
Detected and corrected
Preventable adverse event
occurs
Undetected(may causecascade of
errors)
Beneficial outcome may occur
Unavoidable adverse event
occurs
IF
IF OU
TC
OM
EA
CT
ION
R
QD
OU
TC
OM
EA
CT
ION
R
QD
A, R & G Singh 2002
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IsordilorPlendil?
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Other Example:
-Glucose-Oxygen/CO2
What shall manager do?How can we prevent them?
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• Underestimated by a factor of 20 or greater
• Reports in health care would presumably number in the millions if adverse events, no harm events, and near misses were captured.
Agency for Healthcare Research and Quality, Making Health Care Safer: A Critical Analysis of Patient Safety, July 2001 Donald Holmquest, MD, PhD, JDChief Technology Offices, eMedical Research, Inc. – 3000 medical fatal errors for 1,000,000 people
More Common than We Thought
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Richard Smith
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“Knowing is not enough; we must apply. Willing is not enough; we must do.”
Wolfgang von Goethe
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How to think of error?An individual failing
It will not solve the problem--it will probably in fact make it worse because it fails to address the problem
Doctors will hide errorsMay destroy many doctors inadvertently (the second
victim)A systems failure
This is the starting point for redesigning the system and reducing error
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James Reason’s bottom lineFallibility is part of the human condition
We can’t change the human condition
We can change the conditions under which people work
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• Historically, mistakes or poor outcomes have been blamed on “dumb doctor,” or “dumb nurse.” The “solution” was the ABP reaction – Accuse, Blame and Punish.
• But inefficiencies and errors mostly can be traced not to one error, but a cascade of poor or poorly executed procedures, policies, technologies and training. A good system will provide a good outcome; a poorly designed one will produce a poor one.
•We need to design health care systems that put safety first (First, do no harm)
Hopkins Medical News, Edward D. Miller, M.D., Fall 2002, Page 56
Good Outcomes, Good Systems
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“…adverse events are generally not the result of one thing that went wrong. They result from the combination of a series of latent errors that are built into the system.”
Paul M. Schyve, MD, Vice President, JCAHO In: Reducing Medical Errors, Improving Patient Safety: Taking the Next Step, HealthLeaders Roundtable, June 2001.
A System Problem
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SAFETY BARRIERS
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Theory of Constraints
Any improvement is a changenot every change is an improvement
but we cannot improve something unless we change it
Goldratt (1990)
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any change is a perceived threat to securitythere will always be someone who will look at the
suggested change as a threat
any threat to security gives rise to emotional resistanceyou can rarely overcome emotional resistance with logic
aloneemotional resistance can only be overcome by a stronger
emotionGoldratt (1990)
Any improvement is a change
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“Anyone who thinks you can overcome
emotional resistance with logic was probably
never married”
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Panic Zone•peopleclose up•they freeze•they don’t learn
Comfort Zone•people stay here•they don’t learn
•they don’t change
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Discomfort Zone
Comfort Zone
PanicZone
•uncertainty•learning
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“Tell me and I will forget
Show me and I may remember
Involve me and I will understand”
In comparison with:“See oneDo one
Teach one”
Emotionally, Intellectually and physically
BUT Excluding the EGO
i.e. HALO!
It is important to be aware of:
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19-04-23 39
Involve the nurses
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4 equally important parts of improvement
Process and systems thinking
Making it a habit: initiating, sustaining
and spreading improvement in
daily work
Involving users, carers, staff and
the public
Personal and organisational development
Vision: Every single person is capable, enabled and encouraged to work with others to improve their part of the service
Discipline of improvement in health and social care (Penny 2003)
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Hospital standardised mortality rates by reference costs
50
60
70
80
90
100
110
120
130
140
50 60 70 80 90 100 110 120 130
Reference costs 2002
HS
MR
200
2
Source: ‘Pursuing Perfection’ programme
No relationship between cost and mortality
in UK
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-Glucose-Oxygen/CO2
What shall manager do?How can we prevent them?
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Safety Principles
Error prevention Making errors visible Mitigation of harm from errors
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“No problem can be solved within the same consciousness which caused it.”
Albert Einstein
“Since modern information tools can do things that the unaided human mind cannot do, when we use such tools we may see a picture of medicine we have not seen before.”
Larry Weed
“…there are enormous ‘voltage drops’ along the transmission line for medical knowledge.”
Lawrence Weed (1997)
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Safety in Flying1903 First Powered Flight1908 First Pilot dies1910 First mid-air collision1918 31 of first 40 US Air Mail pilots
die in crashes1994 4 crashes/10,000,000 takeoffs
45
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Flight vs. HealthcareMachine vs. Human (Flight)Human vs. Human (Healthcare)
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“A growing body of evidence supports the conclusion that various types of IT applications lead to improvements in safety… Nonetheless, IT has barely touched patient care.”
Source: IOM, Crossing The Quality Chasm, p. 187.
Information Technology
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Information Technology to Improve Patient Safety
Electronic medical records (EMR)Electronic orders and prescribing:
Computerized Physician Order Entry (CPOE)Electronic decision-support toolsHandheld devices (PDAs) The electronic office
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Technology has Become a Preferred Solution by Many Groups:
IOM reports
Leapfrog
ISMP
Media
Legislators
50
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Order____________________________________
Point o f Care
?
N atriumKaliumCalciumM agnesiumASATALATalkPa segam m aG T
?
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Point of Care
CPOEWatchdog• renal failure?• special dose requirements?• Contraindications?
Dose calculation• single dose• dosing intervall• divisibility
1 2
3
Drug data base• local formulary• common thesaurus
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• Create a clinical data repository consolidation key clinical data• From this database, information can be located efficiently and reliably
Generation I = 15% reduction in preventable errors
Generation I
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• Implementation of basic clinical decision support systems (CDSS) - a key for eliminating errors
GI (15%) + GII (25%) = 40% reduction in preventable errors
Generation II
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Reducing Haphazard Decisions
How fast can Igive this drug ?
Where are the chart & blue card ?
Is there apolicy ?
What’s the lastPotassium ?
What does this child weigh ?
What’s the doseof potassium ?
Protection from Overdose?
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… for example sedation
Midazolam (Dormicum®)
• sedative before interventions (e.g. dental or other surgery, endoscopy)
• sedation in respirator therapy
• emergency treatment of epileptic fits (e.g. status epilepticus)
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Adults
Children
Clin
Pha
rmac
okin
et 9
8;35
:37
Midazolam clearance
0.1
0.2
0
0.3
0.4
0.5
0.6
0.7
L/h/kg
Born 4 8 12 16 20Year
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Adults
Children
Midazolam distribution
Clin
Pha
rmac
okin
et 9
8;35
:37
0.25
0.5
0
0.75
1
1.25
1.5
1.75
L/kg
Born 4 8 12 16 20Year
2
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Adults
Children
Underdosing
Overdosing
Midazolam dosing according to weight
Year
1
2
0
3
4
5
6
Born 4 8 12 16 20
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Renal failure: risk without dose adjustmentIrreversible cerebellar damage
Coma, epileptic fits
Confusion
Arrhythmia, K+
Grandmal
AV-Block
Con
cent
ratio
n in
ren
alfa
ilure
2*
4*
6*
8*
10*
0.5*
D igoxin, I m ipenem
Aciclovir, Cefuroxim e
Lithium
N orm al 75 50 25Renal function
D ialysis
Bisopro lo l
Ranitid ine
Baseline M etopro lo l
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Drug-Drug Interaction
10 combinations
45 combinations
5 drugs
10 drugs
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• Combining CDSS across the continuum of care (in and out patients)• Use of controlled medical vocabulary to normalize medical concepts• CPOE (to better manage ordering)• Work flow improvements• Combining work flow change and CDSS• This 3rd generation has the basic infrastructure to measure or asses incidence of potential errors and measure effectiveness of interventions
GI (15%) + GII (25%) + GIII (30%) = 70% preventable error. IOM goal of at least a 50% reduction of preventable medical
errors
Generation III
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Errors resulting in ADEs: Harvard Study
56%34%
6% 4%
Ordering
Administration
Transcription
Dispensing
64
Bates DW et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.
eMAR & Bar-coding
CPOE
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خوب! راحت باش و روی
بارکدخوان دراز !بکش
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• More sophisticated CDSS• Tailored care to the individual patient• Disease management tracking• Protocols (Care management, Clinical)•GI (15%) + GII (25%) + GIII (30%) + GIV (20%) = 90%
preventable error.
Generation IV
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After the next decade 2010
•Highly sophisticated CDSS•True evidence-based medicine•Outcomes tracking of each episode of care•Links to NLM and new medical research results from the medical literature•Interfaces to mobile personal monitoring devices•Personalized accessible patient record information anywhere
Generation IV
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PEDIATRICS Vol. 116 No. 5 November 2005The Introduction of Computerized Physician Order Entry and Change
Management in a Tertiary Pediatric Hospital
Jeffrey S. Upperman MD; Patricia Staley BA; Kerri Friend BA; Jocelyn Benes RN; Jacque Dailey RNWilliam Neches MD; and Eugene S. Wiener MD
From the Departments of Surgery, Quality and Care Management, and Cardiology, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Conclusion. CPOE is an invaluable resource for supporting patient safety in health care settings.
PEDIATRICS Vol. 116 No. 6 December 2005 Unexpected Increased Mortality After Implementation of a Commercially
Sold Computerized Physician Order Entry System
Yong Y. Han, MD; Joseph A. Carcillo, MD; Shekhar T. Venkataraman, MD; Robert S.B. Clark, MD; R. Scott Watson, MD, MPH; Trung C. Nguyen, MD; Hülya Bayir, MD; and Richard A. Orr, MD
From the Departments of Critical Care Medicine and Pediatrics andClinical Research, Investigation and Systems Modeling in Acute Illness
(CRISMA) Laboratory, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Conclusion. We have observed an unexpected increase in mortality coincident with CPOE implementation.
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وووه! االن تصادف می
! ... کنم
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No. of years for 30% of Americans to own technology:• Telephone 40 years• Television 17 years• PC 13 years• Internet 7 years
D.Z. Sand, HIMSS presentation 2002, Cambridge Technology Partners
Technology Adoption, Change!
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“Physicians had always avoided applying mathematics to the study of the body or disease. In the 1820’s, 200 years after the discovery of thermometers, French clinicians began using them.”
The Great Influenza, John M . Barry p25
Thermometers
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• Physicians were taught to be independent and have been resistant to guidelines and systems• Physicians view teamwork as golf teams not volleyball teams• Disruptive behavior has been tolerated and in some respects rewarded among physicians
Main Barriers
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،مطالعه در حوزه امنیت پزشکی همانند الیه الیه کردن پیاز است،هرچه بیشتر ادامه می دهید بیشتر پیدا می کنید
!و بیشتر گریه می کنید
Point of Care