Patient Safety. Annual Accidental Deaths. Medical Errors in History. How Hazardous Is Health Care (Amalberti)

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1 Patient Safety Annual Accidental Deaths Medical Auto Workplace Air Deaths Total lives lost per year How Hazardous Is Health Care (Amalberti) 100,000 10,000 1, DANGEROUS (>1/1000) HealthCare Mountain Climbing Bungee Jumping REGULATED Driving Chemical Manufacturing Chartered Flights ,000 10, ,000 1,000,000 10,000,000 Number of encounters for each fatality ULTRA-SAFE (<1/100K) Scheduled Airlines European Railroads Nuclear Power Medical Errors in History In my opinion, physicians kill as many people as we generals. -- Napoleon Bonaparte The physician can bury his mistakes, but the architect can only advise his client to plant vines. -- Frank Lloyd Wright, New York Times, 1953

2 Public Perceptions Personal Experience Percent who say they are dissatisfied with the quality of health care in this country * 55% 44% Has the quality of health care in th country Gotten worse 40% 38% Have you been personally involved in a situation where a preventable medical error was made in your own medical care or that of a family member? 21% Did the error have serious health consequences, minor health consequences, or no health consequences at all? Serious health consequences 4% 17% 65% 34% 10% 3% Minor health consequences No health consequences Don t Know Gotten better 1% * Gallup Poll conducted September 11-13, 2000 with 1,008 U.S. adults. Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers Experience Safety and Quality Information, November 2004 (Conducted July 7 September 5, 2005). Health Care Associated Injury/Harm An injury or harm to a patient attributed to the process of care rather than underlying physiological conditions Hazard Anything which has the potential to cause harm Risk The likelihood that somebody or something will be harmed by a hazard, multiplied by the severity of the potential harm. Goals of Patient Safety Reduce the risk of health care associated (caused by treatment) injury to patients Remove or minimize hazards which increase risk of health care associated injury to patients

3 Human Error Formal definition: Error is action or inaction that leads to a deviation from intentions or expectations Informal definition: Human Error is the Downside of Having a Brain Medical Errors are not Unique Share important causal factors with those in other complex systems Transportation Aviation Railroads Automobiles Nuclear power Petrochemical Industry What We Know About Error Human error is ubiquitous and inevitable Errors increase the probability of incidents and accidents Error management strategies can reduce the severity of errors We Make Errors Because of Human Limitations Limited memory capacity Limited processing capacity multi- tasking capability Limits imposed by stressors tunnel vision Limits imposed by fatigue and other physiological factors Poor group dynamics Cultural influences Reason s Types of s and Conditions Categories based on who initiated the failure and how long it takes to have an adverse effect Active failures are errors committed by those in direct contact with the humansystem interface (human error) Latent conditions are the delayed consequences of technical and organizational actions and decisions Sharp End - Active s Individuals at the sharp end are in direct contact with the human-system interface. They administer care to patients. Their actions and decision may result in active failures. Sharp End

4 What is the Role of Allied Health in Patient Safety Allied health professions are at the sharp end of care Clinical leaders are both part of the problem and part of the solution Rasmussen s Model of Human Error Skill based behavior Rule based behavior Knowledge based behavior Skill Based Behavior Perform routine tasks e.g. Driving while listening to the radio, holding a conversation Rule Based Behavior Perform familiar tasks, experience e.g. approach familiar stop sign access stored info = slow car down, look both directions, etc.. Knowledge Based Behavior Novel situation, problem solving at conscious level e.g. traffic lights broken at busy junction Consciously generate solution? Proceed or stop Blunt End - Latent Conditions Individuals at the blunt end take actions and/or make decisions that affect technical and organization policy and procedures and allocate resources. Their actions and decisions may result in latent conditions. Blunt End

5 Misadventures Happen Blunt end actions and decisions create latent underlying conditions + Sharp end actions and decisions create active human failure = Misadventure Latent Latent + Active Active Misadventure Titanic: A Classic Case Study of Latent Conditions Titanic Latent Conditions Blame and Train Inadequate number of lifeboats No transverse overheads on water tight bulkheads No shake down cruise to train crew No training for officers on handling of large single rudder ships Only one radio channel Perfectionism Structure You have had three reported errors Off With Your Head Antecedents Conditions Care Process Outcome Patient Safety Management Encouraging Improvement?

6 Event Adjust structure and process to eliminate or minimize risks and hazards of health care associated injuries before they have an adverse impact on the outcomes of care Is a deviation in an activity or technology that leads toward an unwanted negative consequence (Freitag and Hale) Adverse medical events are the unwanted consequences (harm to a patient) resulting from the process of care Iceberg Model of Accidents and Errors Actually Occurred Misadventure Death\severe harm No Harm Event Potential for harm is present Near Miss Unwanted consequences were prevented because of recovery At Risk Behavior Actual Harm Recovery Heinreich s Ratio 1 It has been proposed that reporting systems could be evaluated on the proportion of minor to more serious incidents reported 2 1 major injury 29 minor injuries 300 no- injury accidents 1. Heinreich HW Industrial Accident Prevention, NY And London An Organization With a Memory, A report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer, The Stationary Office, London