Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. webinars@thinkreliability.com www.thinkreliability.com Office 281-412-7766 Houston, TX Healthcare Case Study WHAT are errors? errors are preventable events that lead to s being used inappropriately. errors that cause harm are called adverse drug events. drug dose patient time rate preparation route of administration Copyright ThinkReliability 1
Healthcare Case Study: Errors Impacts of Errors Preventable adverse drug events in hospitals are estimated to injure hundreds of thousands of people and cost >$37B per year in the US. Per Institute of Medicine, a hospital patient can expect on average to be subjected to more than one error per day. Death or serious disability associated with a error is a never event (National Quality Forum) NHS Never Events Mis-selection of a strong potassium containing solution (rather than an intended different ) route administration of Intravenous chemotherapy via the intrathecal route Oral/enteral or feed/flush by an parenteral route Intravenous administration of a medicine intended to be via the epidural route Copyright ThinkReliability 2
Healthcare Case Study: Errors NHS Never events (cont.) Overdose of insulin due to abbreviations or incorrect device Overdose of methotrexate for non-cancer treatment Mis-selection of high strength midazolam during conscious sedation Canadian Safety Institute Never Events death or serious harm due to a failure to inquire whether a patient has a known allergy to, or due to administration of a where a patient s allergy had been identified. Copyright ThinkReliability 3
Healthcare Case Study: Errors Canadian Safety Institute Never Events (cont.) death or serious harm as a result of one of five pharmaceutical events -route administration of chemotherapy agents Intravenous administration of concentrated potassium solution Inadvertent injection of epinephrine intended for topical use Overdose of hydromorphone by administration of a higher-concentrated solution than intended Neuromuscular blockade without sedation, airway control and ventilation capability NOW WHAT do we do to reduce patient risk? Review administration process Causes of errors Case studies Copyright ThinkReliability 4
Healthcare Case Study: Errors Delivery Process Delivery Process prescribed transcribed prepared to patient Physician Pharmacist Nurse Process Map Prescribed/ Transcribed dose selected not informed about Physician determines patient need for Physician selects Physician selects dose Physician writes/ enters prescription Physician explains prescription to patient selected / dose written/ entered Copyright ThinkReliability 5
Healthcare Case Study: Errors Process Map Prepared/ Administered dose selected /dose route/ timing not monitored Pharmacist selects Pharmacist measures labeled delivered to patient to patient monitored selected / dose labeled given to wrong patient Errors Error Reporting Errors by Stage Administering 38% Prescribing 39% Dispensing 11% Transcribing 12% Copyright ThinkReliability 6
Healthcare Case Study: Errors New study: Pharmacy Errors Study of >1.8M orders at medical center in Texas found the following error rates per 100 shifts: 2.58 for 100-200 verified orders per shift 8.44 for 201-400 verified orders per shift 11.11 for >400 verified orders per shift Overall error rate is 4.87 errors per 100,000 verified orders Case study 1: Infant Heparin Overdoses Step 1. Outline What When Where Impact to the Goals Problem(s) Date Time Different, unusual, unique Facility, site Unit, area, equipment Task being performed Safety Compliance Services Labor/ Time Adult heparin dose given to 6 newborns September 16, 2006? Saturday; dose 1000x higher Indianapolis, IN NICU Administration of heparin (blood thinner) 3 fatalities, premature newborns 3 critical condition premature newborns Never event Incorrect drug dose delivery Investigation Frequency 16,000 incorrect dosing errors between 2001-2006 Copyright ThinkReliability 7
Healthcare Case Study: Errors Heparin Overdoses Heparin to infants Safety Goal Impacted 3 infant fatalities, 3 critical injuries dosage heparin dosage removed from bottle checks ineffective Heparin Overdoses Heparin to infants Used to prevent blood clots Risk of clogging intravenous (IV) tubes Drugs, food, water via IV Copyright ThinkReliability 8
Healthcare Case Study: Errors Heparin Overdoses Heparin to infants Safety Goal Impacted 3 infant fatalities, 3 critical injuries dosage heparin dosage removed from bottle checks ineffective Heparin Overdoses dosage removed from bottle dosage removed from cabinet dosage in cabinet dosage removed from pharmacy 10 unit/10,000 unit bottles look similar checks ineffective Copyright ThinkReliability 9
Healthcare Case Study: Errors Heparin Overdoses Heparin to infants Safety Goal Impacted 3 infant fatalities, 3 critical injuries dosage heparin dosage removed from bottle checks ineffective Heparin Overdoses checks ineffective dose not verified Nurse accustomed to only one dose NICU stocks only one dose of heparin Copyright ThinkReliability 10
Healthcare Case Study: Errors Heparin Overdoses Step 3. Solutions dosage heparin Heparin to infants dosage removed from bottle Solution: Review check process checks ineffective Solution: Use saline to flush IVs Used to prevent blood clots dosage removed from cabinet dose not verified Risk of clogging intravenous (IV) tubes Drugs, food, water via IV dosage in cabinet Nurse accustomed to only one dose Solution: Computer delivery system dosage removed from pharmacy NICU stocks only one dose of heparin Solution: Redesign bottles 10 unit/10,000 unit bottles look similar checks ineffective Case study 2: Mistaken Administration of Paralytic Agent Step 1. Outline What When Where Problem(s) Date Time Different, unusual, unique Facility, site Unit, area, equipment Task being performed Impact to the Goals Safety Employee Compliance Services Labor/ Time death, error December 1, 2014? Fire alarm (code red) at facility Bend, Oregon Hospital emergency room Administration of IV anti-seizure death 3 employees placed on administrative leave Never event not monitored after IV administration Investigation Frequency First time hospital has had issue like this Copyright ThinkReliability 11
Healthcare Case Study: Errors Paralytic Agent Administration Safety Goal Impacted death Cardiac arrest/ brain damage stopped breathing paralyzing agent via IV Evidence: Rocuronium Delay in treatment/ response not monitored after IV Paralytic Agent Administration prescribed anti-seizure Evidence: Fosphenytoin Sought treatment in ER paralyzing agent via IV put in IV bag Error in pharmacy IV bag marked for prescribed (correct) drug Copyright ThinkReliability 12
Healthcare Case Study: Errors Paralytic Agent Administration Safety Goal Impacted death Cardiac arrest/ brain damage stopped breathing paralyzing agent via IV Evidence: Rocuronium Delay in treatment/ response not monitored after IV Paralytic Agent Administration Staff unavailable Fire alarm went off not monitored after IV * Evidence: For ~20 minutes, per staff s door closed Protection from potential fire hazards *The hospital has determined that the patient not being monitored was not a causative factor in the patient s death. Copyright ThinkReliability 13
Healthcare Case Study: Errors Paralytic Agent Administration Step 3. Solutions Solution: Add alert stickers to paralytic agents paralyzing agent via IV prescribed anti-seizure Evidence: Fosphenytoin put in IV bag Sought treatment in ER Solution: Update protocols; implement detailed checking process & safety zone for verification Error in pharmacy IV bag marked for prescribed (correct) drug NOW WHAT Identify possible improvements to process Minimize distractions Add a double check Alerts/ guides for high risk Remember the 5 Rights of safety: Right Right dose Right time Right route Right patient Copyright ThinkReliability 14
Healthcare Case Study: Errors Cause Mapping Problem Solving Incident Investigation Root Cause Analysis Errors Angela Griffith, P.E. webinars@thinkreliability.com www.thinkreliability.com Office 281-412-7766 Houston, TX Healthcare Case Study Resources Comprehensive guide to safety: http://www.ismp.org/tools/pathwaysection2.pdf Causes of administration errors in hospitals (human behavior category based): http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3824584/ Pharmacy study: http://www.pharmacytimes.com/news/what-makespharmacist-mistakes-more-likely California study (error rates in process): http://www.chcf.org/~/media/media%20library%20files /PDF/PDF%20A/PDF%20addressingmederrorsframework. pdf Copyright ThinkReliability 15