# Presentation: 007668

- 2009

## Questions are the Answer http://www.ahrq.gov/questionsaretheanswer/

## “I would give great praise to the physician whose mistakes are small, for perfect accuracy is seldom seen... .” Hippocrates, trans. by Francis Adams. On Ancient Medicine, Part 9; c. 400 BCE. 

Traditional Errors in Surgery. Levis RJ. Presidential Address, Medical Society of the State of Pennsylvania on June 6, 1888.  JAMA. 1888 (Jun 23);10(25):790-791.

To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press; 2000.

- Traditional Errors in Surgery. Levis RJ. Presidential Address, Medical Society of the State of Pennsylvania on June 6, 1888.  *JAMA.* 1888 (Jun 23);10(25):790-791.
*To Err is Human: Building a Safer Health System.** *Kohn LT, Corrigan JM, Donaldson MS. Washington, DC: National Academy Press; 2000.

**Patient Safety: Ongoing Problem**

**Notes:**
First of what became known as the Quality Chasm Series published by the Institute of Medicine and available online through the National Academies Press – www.nap.edu

## Aviation Industry
Federal Aviation Authority (FAA): Aviation Safety Reporting System (ASRS) – 1975 
National Aeronautics and Space Administration (NASA) : NASA Safety Reporting System (NSRS) – 1987
Transportation Industry
National Transportation Safety Board (NTSB) – 1966 
UK Railway Industry: Confidential Incident Reporting & Analysis System (CIRAS) – 1996 

**Aviation Industry**
- Federal Aviation Authority (FAA): Aviation Safety Reporting System (ASRS) – 1975
- National Aeronautics and Space Administration (NASA) : NASA Safety Reporting System (NSRS) – 1987
**Transportation Industry**
- National Transportation Safety Board (NTSB) – 1966
- UK Railway Industry: Confidential Incident Reporting & Analysis System (CIRAS) – 1996

## Nuclear Energy Industry
US Nuclear Regulatory Committee (NRC) – 1974 
Computerized Accident Incident Reporting and Recordkeeping System (CAIRS) -1975
Manufacturing Industry 
Toyota Production System – 1977 
Alcoa Aluminum: Safety Culture – 1987  
General Electric: Six Sigma - 1995

**Nuclear Energy Industry**
- US Nuclear Regulatory Committee (NRC) – 1974
- Computerized Accident Incident Reporting and Recordkeeping System (CAIRS) -1975
**Manufacturing Industry**
- Toyota Production System – 1977
- Alcoa Aluminum: Safety Culture – 1987
- General Electric: Six Sigma - 1995

## 	Patient safety: Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.

 Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000:211. 

- 	_**Patient safety**_: Freedom from accidental injury; ensuring patient safety involves the establishment of operational systems and processes that minimize the likelihood of errors and maximize the likelihood of intercepting them when they occur.
-  Kohn LT, Corrigan JM, Donaldson MS. *To err is human: building a safer health system. *Washington, DC: National Academy Press; 2000:211.

**Notes:**
Important especially where consumers want to research this issue.

This is a working definition.  Different institutions may have different definitions. 

## Definitions in Patient Safety

**Definitions in Patient Safety**

**Error: failure of a planned action or use of a wrong plan **

**Notes:**
Error: An error is 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). An error may be act of commission or an act of omission. {Patient safety: achieving a new standard for care. pg:30}

Adverse event: An adverse event results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. (This definition makes it clear that the potentially avoidable results of an underlying disease or condition, for example, a recurrent myocardial infarction in a patient who was not given a beta-blocker (an error of omission), should be considered an adverse event.) {Ibid. pg 32}

Near miss: A near miss is an act of commission or omission that could have harmed the patient but did not cause harm as a result of chance, prevention, or mitigation. {Ibid. pg 34}

Sentinel event: A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. {JCAHO}

## Definitions in Patient Safety

**Definitions in Patient Safety**

**Adverse Event / Clinical Event**

**Sentinel Event**

**Preventable Adverse Event**

- Adapted from: MMS Committee on Quality of Medical Practice and Trinity Communications, Inc.  *Medical Errors and Perspectives on* *Patient Safety*. Massachusetts Medical Society, 2004.

**Error**

***Not all events must be reported. ***

**Notes:**
Adverse Event: an injury caused by medical management. An injury is harm caused by an external force or action. An adverse event may or may not be preventable. {MMS}
In this case, this does NOT refer to malpractice or deliberate errors.  
Adverse or Clinical events are, for example, an unpredictable reaction to a drug.

Preventable adverse event: an adverse event caused by error.

Reportable events depend on institution and state requirements. This may be why events an individual has experienced was not reported.

## No health professional 
begins their day
with the goal of making a mistake 
and harming their patient. 

However, 
there are problems in the system
that can lead to errors.

- No health professional
- begins their day
- with the goal of making a mistake
- and harming their patient.
- However,
- there are problems in the system
- that can lead to errors.

## Jose Eric Martinez, died August 2, 1996
   At least 17 errors contributed to the death of this infant:
4 physician events 
2 pharmacy events 
4 medication policy issues
2 authority gradient issues
2 response issues
1 shift change issue
1 mechanical issue
1 violation (not following policy)

-    At least 17 errors contributed to the death of this infant:
- 4 physician events
- 2 pharmacy events
- 4 medication policy issues
- 2 authority gradient issues
- 2 response issues
- 1 shift change issue
- 1 mechanical issue
- 1 violation (not following policy)

**Sentinel Event**

- Turnbull JE. Systems approach to error reduction in health care.  *Japan Med Assoc J.* 2001(Sep);44(9):392-403

**Notes:**
Why haven’t we “solved patient safety” after five years?
Jose Eric Martinez, August 2, 1996, 17 errors in Root Cause Analysis {Turnbull}
Bad Apple analogy - fire nurse, however – even with the new nurse there is the possibility for the same error to occur (and it has, but references are few)
(For reference only - if someone asks)

Physician: 
    wrong medication amount written on order, verification by second doctor missed decimal point, recalculation by third doctor missed wrong decimal point, physician dismissed nurses’ concern
Pharmacy: 
   no follow-up on questioned order (after no response), not caught when tech filled order
Medication policy:  
   no clear policy on questioning orders, handwritten form, use of zeros, infant weight not required
Authority gradient: 
   pharmacist to nurse, nurse to physician
Response issues: 
   resident to pharmacist, nurse to pharmacist
Shift change: 
   resident gave verbal information to next shift
Mechanical issue: 
   beeper turned off
Violation: 
   faxed order to pharmacy followed by hard copy

## Patient Safety Systems

**Patient Safety Systems**

- Barrier/Defense

- Patient

**Notes:**
Many mistakes are caught before they reach the patient

Near Miss
	Missed diagnosis by physician – caught after shift change {Cosby}
	Nurse brings up issue – Physician responds to problem {Turnbull}
	Prescription error by resident – caught by presiding {Turnbull}

Barriers include not only individuals, but policies and procedures of in department 

## Patient Safety Systems

**Patient Safety Systems**

- Adapted from: Reason J. Human error: models and management*. BMJ* 2000;320;768-770

**Notes:**
You could ask the consumers which types of errors/mistakes/problems they may know about in each area.  
The goal is to highlight the fact there may be problems at every level and that, as patients or patient advocates, they need to be aware of potential problems at every level.

Emergency Room
    Latent: Overcrowding lead to fatal treatment delay {Trzeciak}
    Active: 10% of all pediatric emergency patients experienced prescribing errors {Kozer, Lesar}
    Latent: 7% of errors were due to equipment failures {Thomas}

Administration
    Barcodes were switched on two patients leading to a potentially fatal near-miss {McDonald}
    2% of wristbands contained errors {Renner}

Laboratory 
    3% of test orders not completed {Matlow}
    Specimens mislabeled {Sazama, Bonini}

Transfers 
   Transfers/handoffs between persons, shifts, floors, departments, buildings, institutions
    Verbal information from day resident to night did not match information on written orders {Turnbull}
   Recent study showed 43% of communication breakdowns occurred with handoffs.  Of all the communication errors in this study, 3% were across institutions, 19% between departments and 78% within one department {Greenberg}

Physician
    Latent error: Studies show after 24 hours, 20% more mistakes and took 14% longer to complete tasks. {Taffinder}
    Active error: Interruptions/Fatigue/Assumptions leading to missed diagnosis - Brain cramp {Yee}

Pharmacy – medication errors most completely studied of all errors
    Similar packaging / Sound-alike names - “Celebrex – Cerebyx – Celexa” {JCAHO}
    Can’t get a hold of physician {Turnbull}

Nurse
Considered the front line of defense and expected to catch every error.  However, there are a number of conditions for nurses that may lead to mistakes being made.
    Understaffed {Savill}
    Transfusion given to patient in same room or to patient with same last name {McDonald, Sazama}
    Didn’t expect adult doses in children’s drawer {Wilson}

Patient / Family 
Can help prevent errors from reaching a patient
    Communication, language {Shapiro}
    Not giving full history of illness or homeopathic medicines {Shapiro}
    Patient warning of [transfusion] problem ignored {Sazma}

Error winds it’s way through the system, patient injured or killed, sentinel event. {Reason}

## System Errors (Latent)
Communication Heavy workload/Fatigue
Incomplete or unwritten policies
Inadequate training or supervision
Inadequate maintenance of equipment/buildings

_**System Errors **__**(Latent)**_
- Communication Heavy workload/Fatigue
- Incomplete or unwritten policies
- Inadequate training or supervision
- Inadequate maintenance of equipment/buildings

_**Human Mistakes **__**(Active)**_
- Action slips or failures (e.g. picking up the wrong syringe)
- Cognitive failures (e.g. memory lapses, mistakes through misreading a situation)
- Violations (i.e. deviation from standard procedures; e.g work- arounds)

- DeLisa JA.  Physiatry: medical errors, patient safety, patient injury, and quality of care.  *Am J Phys Med Rehabil. *2004(Aug);83(8):575-583

## Understanding systems 
and processes
leads to asking the right questions
to find answers 
to what has occurred
and what might happen again.  

- Understanding systems
- and processes
- leads to asking the right questions
- to find answers
- to what has occurred
- and what might happen again.

**Notes:**
Working definition – important to know what the definition is in your institution

## Processes
Medication delivery 
prescribing, preparation, point-of-care delivery
Tests 
pre-analysis, analysis, post-analysis
Surgery 
preparation, procedures, follow-up
Patient transfers & hand-offs
from care centers, during shift changes, across floors
Communication
reporting, information sharing, encouragement/resistance

- Medication delivery
- prescribing, preparation, point-of-care delivery
- Tests
- pre-analysis, analysis, post-analysis
- Surgery
- preparation, procedures, follow-up
- Patient transfers & hand-offs
- from care centers, during shift changes, across floors
- Communication
- reporting, information sharing, encouragement/resistance

**Be Aware of Potential Problems**

**Notes:**
Even environment can play a part in the problems {Ulrich}

## Individual Advocacy – In doctor and hospital visits
Share information 
Create and bring lists of health problems, previous operations, etc.
List or bring all medications, supplements, and vitamins
Get information
Ask questions about treatments, medications, etc. 
Research illnesses and treatments

**Individual Advocacy **– In doctor and hospital visits
**Share information**
- Create and bring lists of health problems, previous operations, etc.
- List or bring all medications, supplements, and vitamins
**Get information**
- Ask questions about treatments, medications, etc.
- Research illnesses and treatments

## Individual Advocacy – In doctor and hospital visits
Bring an Advocate
To appointments
At the bedside in the hospital
Know what to do before leaving
Ask about medications 
Ask about future appointments 

**Individual Advocacy **– In doctor and hospital visits
**Bring an Advocate**
- To appointments
- At the bedside in the hospital
**Know what to do before leaving**
- Ask about medications
- Ask about future appointments

## Patient Advocate – For friends and family
Go with the patient to appointments, be with them in the hospital
Listen and take notes
Speak up when necessary to clarify an issue and to ask a question
Question when something does not seem right in the hospital, nursing homes, clinics, etc.

**Patient Advocate **– For friends and family
- Go with the patient to appointments, be with them in the hospital
- Listen and take notes
- Speak up when necessary to clarify an issue and to ask a question
- Question when something does not seem right in the hospital, nursing homes, clinics, etc.

**Notes:**
Advocate {NPSF} – going with patient to doctor/ hospital, being willing to speak up.  

## Patient Representative – In health care organizations 
Working to improve safety at the organization and individual unit level
Serving on committees and boards
Assisting on rounds (still rare)
Supporting staff and families related to patient safety events

**Patient Representative **– In health care organizations
- Working to improve safety at the organization and individual unit level
- Serving on committees and boards
- Assisting on rounds (still rare)
- Supporting staff and families related to patient safety events

**Notes:**
Representative {Frankel (2005), Munch} 
   More and more hospitals are including patient representatives on committees, boards and even rounds.  
   Some hospitals include patient families in their studies of events (e.g. root cause analysis) {Munch}

## Patient Participant/Activist
Participate on state and regional coalitions and organizations and/or
Serve nationally 
Advocate for public reporting and accountability of hospital and health system performance 
Volunteer, make donations, work with fund-raising
Be aware of state and national legislation, contact legislators 

**Patient Participant/Activist**
- Participate on state and regional coalitions and organizations and/or
- Serve nationally
- Advocate for public reporting and accountability of hospital and health system performance
- Volunteer, make donations, work with fund-raising
- Be aware of state and national legislation, contact legislators

- Gibson, Rosemary. Role of the patient in improving patient safety. *WebM&M.* 2007(Mar): Perspectives on Safety. _[http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38](http://webmm.ahrq.gov/perspective.aspx?perspectiveID=38)_

**Notes:**
National {Gibson} – Being aware of legislation, being on listservs, participating in groups such as
	Consumers Advancing Patient Safety - www.patientsafety.org
	Josie King Foundation - josieking.org
	Medically Induced Trauma Support Services - mitss.org
 	Pulse America - pulseamerica.org

## 
When a near miss or  
a preventable or unpreventable 
adverse event occurs
a variety of resources are available
on the web and in the hospital

- When a near miss or
- a preventable or unpreventable
- adverse event occurs
- a variety of resources are available
- on the web and in the hospital

**Notes:**
Working definition – important to know what the definition is in your institution

## Online Information
5 Steps to Safer Health Care http://www.ahrq.gov/consumer/5steps.htm
20 Tips to Prevent Medical Errors http://www.ahrq.gov/consumer/20tips.htm
Be Prepared for Medical Appointments http://www.ahrq.gov/qual/beprepared.htm
We Care about Your Safety (video) http://www.ashrm.org/ashrm/foundation/emmisafety/
Speak Up Initiatives (and brochures) http://www.jointcommission.org/PatientSafety/SpeakUp/

**Online Information**
**5 Steps to Safer Health Care** http://www.ahrq.gov/consumer/5steps.htm
**20 Tips to Prevent Medical Errors** http://www.ahrq.gov/consumer/20tips.htm
**Be Prepared for Medical Appointments** http://www.ahrq.gov/qual/beprepared.htm
**We Care about Your Safety **(video) http://www.ashrm.org/ashrm/foundation/emmisafety/
**Speak Up Initiatives** (and brochures) http://www.jointcommission.org/PatientSafety/SpeakUp/

## Online Information
Check Your Medicines: Tips for Using Medicines Safely http://www.ahrq.gov/consumer/checkmeds.htm
Drug Information Portal             http://druginfo.nlm.nih.gov/
My Medicine Record http://www.fda.gov/cder/consumerinfo/my_medicine_record.htm 
Questions are the Answer (video) http://www.ahrq.gov/questionsaretheanswer/
What You Can Do to Make Healthcare Safer http://www.npsf.org/download/WhatYouCanDo.pdf

**Online Information**
**Check Your Medicines: Tips for Using Medicines Safely **http://www.ahrq.gov/consumer/checkmeds.htm
**Drug Information Portal**             http://druginfo.nlm.nih.gov/
**My Medicine Record** http://www.fda.gov/cder/consumerinfo/my_medicine_record.htm** **
**Questions are the Answer*** *(video)* *http://www.ahrq.gov/questionsaretheanswer/
**What You Can Do to Make Healthcare Safer **http://www.npsf.org/download/WhatYouCanDo.pdf

## More Information
Websites: AHRQ, NLM, etc.
Alerts: My NCBI, etc.
Organizations: staff, committees, leaders, etc.
Conferences: NPSF, etc.
Advocacy 
Websites: CAPS, PULSE, NPSF, etc.
Legislation resources
Medical Error Support
Websites: MITSS, PULSE, Voice4Patients

**More Information**
- Websites: AHRQ, NLM, etc.
- Alerts: My NCBI, etc.
- Organizations: staff, committees, leaders, etc.
- Conferences: NPSF, etc.
**Advocacy **
- Websites: CAPS, PULSE, NPSF, etc.
- Legislation resources
**Medical Error Support**
- Websites: MITSS, PULSE, Voice4Patients

**Notes:**
These are all included in the “Patient Safety Web References and Resources” handouts, but  we wanted to highlight the different kinds of available resources.

## Exploring Patient Safety Issues
PubMed 
search for similar events and/or processes
My NCBI Alerts 
tracked related events/processes
NIH Clinical Alerts & Advisories
My NCBI Collections 
save related citations for reference, publication, JCAHO, etc.

**PubMed**** **
- search for similar events and/or processes
**My NCBI Alerts**
- tracked related events/processes
**NIH Clinical Alerts & Advisories**
**My NCBI Collections**
- save related citations for reference, publication, JCAHO, etc.

**NLM Resources**

## Exploring Patient Safety Issues 
PubMed Clinical Queries 
identify related reviews
HSDB in TOXNET 
	follow-up on toxicology issues in the Hazardous Substance Data Bank
HSRProj 
current projects on topics
Radiation Event Medical Management 
focusing on all aspects of radiation events

**PubMed Clinical Queries**
- identify related reviews
**HSDB in TOXNET**
- 	follow-up on toxicology issues in the Hazardous Substance Data Bank
**HSRProj **
- current projects on topics
**Radiation Event Medical Management **
- focusing on all aspects of radiation events

**NLM Resources**

## Addressing Additional Concerns
MedlinePlus 
	general searches, patient safety page
Household Products Database 
	toxicology issues
ClinicalTrials.gov 
	current and previous studies
ToxTown 
	 toxicology geared for school children

**MedlinePlus**
- 	general searches, patient safety page
**Household Products Database**
- 	toxicology issues
**ClinicalTrials.gov**
- 	current and previous studies
**ToxTown **
- 	 toxicology geared for school children

**NLM Resources**

## 
    Quality	                                                    Safety

                                                                 Patient and
 Patient                                                            family
 Safety                                                             involvement

                                                                      Culture
  Management

-     **Quality**	                                                    **Safety**
-                ** ****                                                 ****Patient and**
** ****Patient                                                            family**
** ****Safety                                                             involvement**
**                                                                      ****Culture**
**  ****Management**

**Intersection of Patient Safety**