Medical Error
Jeff Plant MD FRCPC
June 27, 2002
Outline Importance of the issue Why are we prone? Personal error Systemic error Dealing with error Where to go from here?
Medical Error Missed Salter 3 fracture
Sent home in post. slab as ?salter 1 #
Missed pyloric stenosis Sent home with anti-reflux measures
Missed volvulus Sent home as viral URTI
And so, the process begins…
What is Error? Error - the failure of a planned action to be
completed as intended or the use of a wrong plan to achieve a goal
Active error (sharp end) Occur at the level of the front-end and their effects
are felt almost immediately Latent error (blunt end)
Removed from the direct control of the operator
Why is this important? To Err is Human:Building a Safer Health
Care System “…when agreement has been reached to
pursue a course of medical treatment, patients should have the assurance that it will proceed correctly and safely so they have the best chance possible of achieving the desired outcome.”
Why is this important? Estimated that between 1-4% of
hospitalizations effected by error 5-20% of errors led to death Eighth leading cause of death in US
(more than MVC’s or AIDS)
Why is this important? Estimated that 40-60% of all diagnoses
wrong Effect on physician… Effect on patient/society…
What do patients expect? Witman et al, 1996 Arch Int Med
They want admission and, if necessary, apology for error
Half as likely to proceed with litigation if error admitted by physician
Why are we prone? Medical culture
Usually no mass casualties Socialized to view error as negligence Responsible for everything that happens to
your patient No admission of error The People’s Court…
Why are we prone? Emergency medicine
Living in a fishbowl Held to high standards Complex and tightly coupled system Time sensitive Multiple tasks ongoing
Medical Error - Personal Four steps of decision making
Data gathering Integration and processing of information Confirmation of diagnosis treatment
Data gathering New patient each
encounter Compressed time Too focused Inaccuracies of
physical exam Difficult setting
Integration and processing Voytovich et al
Lack of knowledge Premature closure Inadequate synthesis Omission
Premature closure highly prevalent and independent of level of training
Integration and processing Errors in cognition
Slips occur with errors in automatic tasks
Mistakes occur with errors in knowledge-based function
Physiologic and psychologic factors make these more likely
Confirmation of diagnosis Historical bias Inherent
strengths/weakness of test
Availability of test Cost of test
Treatment Medication errors Technical errors Pharmaceutical
company interests EBM = economic
based medicine
Medical Error - System Emergency departments are complex
and tightly coupled systems Complex
multiple interactions with other systems multiple feedback loops information often received indirectly
Medical Error - System Tightly coupled
Many time dependent processes arranged in sequences
No tolerance for delays in processes Sequences fixed
Medical Error - System Conditions that create error (DEPOSE)
Design Equipment Procedures Operators Supplies Environment
How do we cope? Most common coping mechanisms:
Denial of responsibility (blame the system) Discounting size of effect Emotional distancing
Less than half discuss errors with patients
1/3-1/2 discuss errors with colleagues
How should we cope? Accept responsibility for error Discuss with colleagues Disclose and apologize to patients Conduct an error analysis Make changes to reduce further errors Change medical culture locally and
nationally in dealing with error
New Look Systems rather than
people Nonpunitive approach Emphasize
multifactorial aspect Errors will occur Caregiver interactions Sharp and blunt end
Systems rather than people All errors are, in the end, a reflection of
the system Analysis of all components DEPOSE
Nonpunitive approach View errors as opportunity to improve
the system Training vs. punishment Encourage self-reporting to
colleague/committee
Emphasize multifactorial aspect Emergency dept is complex Errors rarely occur in isolation
Errors will occur Design systems with this in mind Develop buffers Ritualize behavior
Caregiver interactions Improve communication Formal signovers Computer documentation of patient
status and primary caregiver Clear expectations and roles of each
caregiver
Sharp and blunt end Focusing on front-line is most visible Blunt end tends to harbor latent errors Blunt end decisions drive sharp end
The Teams Approach MedTeams project extrapolation of aviation experience Identification of core team responsible
for patient 5 step approach
Teamwork approach Everyone’s opinion
respected -allowing for each individual’s expertise
Builds in certain degree of redundancy
Teamwork Each team
responsible for specific area
Color-coded http://team.drc.com Report cost savings
of $3-10 per patient
Conclusions Medical errors occur at a very high rate There are both personal and system
aspects of medical error Important to acknowledge error Go through intellectual exercise of
determining why error occurred See error as chance to improve system
Questions?
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