Patient Safety

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Patient Safety

Prevention of Medical Errors

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Why are we here?

• Concern over incidence of Medical Errors

• IOM Report (1999)– To Err is Human, Building a Safer

Healthcare System– Statistics

•44,000 – 98,000 Hospital deaths due to medical error each year

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Why are we here?

• To commit to paying greater attention to the problem

• We make a difference one at a time• To evaluate current approaches• To build better systems to reduce

the incidence of error

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Why are we here?• 2001 FL Legislative response

– FS 456.013– Mandates 2 hour course for ALL health

care providers as part of licensure and renewal process

• Course shall include the study of:– root-cause analysis– error reduction– error prevention– patient safety

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Why are we here?

•FL BON Requirement –64B9-5.011–Continuing Education on Prevention of Medical Errors

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FL BON Requirement• Subject Areas:

– Factors that impact the occurrence of medical errors

– Recognizing error-prone situations– Processes to improve patient

outcomes– Responsibilities for reporting– Safety needs of special populations– Public education

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Definitions

•Error (IOM report):–The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim

–Error of Execution–Error of Planning

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Definitions

•Adverse Events:– Injury caused by medical management rather than underlying disease condition

–Unpreventable–Preventable

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Definitions

•Medical Error–Preventable adverse events with our current state of medical knowledge

–Not defined as intentional act of wrongdoing

–Not all rise to level of medical malpractice or negligence

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Reporting Requirements

• Florida Law requires all licensed facilities to:– Have Internal Risk Management and

incident reporting system– Report Serious Adverse Events to:

•AHCA Agency for Health Care Administration

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Joint Commission

•National organization–Mission to improve the quality of care in healthcare institutions

–Provides Accredited status to healthcare facilities

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Joint Commission•Defines Sentinel Event:

–An unexpected occurrence involving death of serious physical or psychological injury or risk thereof

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Joint Commission

•Sentinel events subject to review by Joint Commission–an event resulting in unanticipated death or major permanent loss of function not related to the underlying condition or if the event is one of the following:

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•Suicide in setting with 24 hour care or within 72 hours of discharge

•Unanticipated death of a full-term infant

•Abduction of any patient •Discharge of infant to wrong family•Rape•Hemolytic Transfusion Reaction involving blood group incompatibilities

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Joint Commission• Requires:

– Process in place to recognize sentinel events

– Credible root cause analysis– Focus on systems not individuals– Risk reduction strategies– Internal corrective action plan

•Measure effectiveness of process•System improvements to reduce risk

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Root Cause Analysis• Goal-directed, systematic process• uncovers basic factors that

contribute to medical error• Focuses primarily on systems and

processes and not individuals• Product of root cause analysis is an

action plan to reduce risk of similar future events

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Root Cause Analysis

• Gather facts• Assemble team• Determine sequence of events

• Identify causal factors• Select root causes• Take corrective action and follow-up plan

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Joint Commission • Sentinel Event Statistics

– Type– Setting– Outcome– Root Causes – And more

• Sentinel Event Alerts– Periodic publication– Sharing information

• To share information• To prevent medical errors/adverse events

• Website: http://www.jointcommission.org/

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Sentinel Events by Type Dec. 31, 2006

• 1. Wrong Site Surgery (13.1%)• 2. Patient Suicide (12.8%)• 3. Op/Post-op Complication(12.1%)• 4. Medication Error (9.5%)• 5. Delay in Treatment (7.4%)• 6. Patient Fall (5.5%)• 7. Patient death/injury in

restraints (3.8%)

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Sentinel Events by Setting Dec. 31, 2006

• 1. General Hospital (67.9%)• 2. Psychiatric Hospital (10.8%)• 3. Psych unit in general hosp.

(4.9%) • 4. Behavioral health facility (4.6%)• 5. Emergency Dept. (3.9%)• 6. Long Term Care Facility (3.0%)• 7. Ambulatory Care (2.7%)

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Root Causes of ALL Sentinel Events 1995-2005

• 1. Communication• 2. Orientation / Training • 3. Patient Assessment• 4. Staffing• 5/6. Availability of Info; Competency / Credentialing• 7. Procedural compliance• 8. Environmental Safety / Security

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Root Causes of ALL Sentinel Events - 2006

• 1. Communication• 2. Patient Assessment• 3. Leadership• 4. Procedural Compliance• 5. Environ. Safety / Security• 6. Competency / Credentialing• 7. Orientation / Training• 8. Availability of Info

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Root Causes – Wrong Site Surgery 1995-2004

• 1. Communication• 2. Orientation / Training• 3. Procedural compliance • 4. Availability of Info • 5. Patient Assessment • 6. Leadership• 7. Competency / Credentialing• 8. Organizational Culture

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Root Causes – Wrong Site Surgery 2005

• 1. Communication• 2. Procedural compliance• 3. Leadership• 4. Competency / Credentialing• 5. Availability of Info• 6. Organizational Culture• 7. Orientation / Training• 8. Patient Assessment; Care

Planning

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Root Causes – Wrong Site Surgery 2006

• 1. Procedural compliance • 2. Communication• 3. Leadership• 4. Availability of Info • 5. Competency / Credentialing• 6. Orientation / Training• 7. Patient Assessment;

Organizational Culture• 8. Environmental Safety / Security

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Root Causes – Suicide 1995-2004

• 1. Environmental Safety / Security

• 2. Patient Assessment• 3. Orientation / Training• 4. Communication• 5. Availability of Information• 6. Continuum of Care• 7. Competency / Credentialing• 8. Staffing levels

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Root Causes – Suicide 2005

• 1. Patient Assessment• 2. Environmental Safety / Security• 3. Communication • 4. Orientation / Training• 5. Competency / Credentialing• 6. Availability of Information• 7. Leadership• 8. Procedural Compliance &

Continuum of Care

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Root Causes – Op/Post-op Complications 1995-2004

• 1. Orientation / Training• 2. Communication• 3. Procedural compliance• 4. Patient Assessment• 5. Staffing• 6. Competency / Credentialing &

Availability of Info• 7. Care Planning• 8. Leadership

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Root Causes – Op/Post-op Complications 2005

• 1. Communication • 2. Patient Assessment• 3. Procedural compliance• 4. Care Planning • 5. Availability of Info • 6. Organizational Culture• 7. Competency / Credentialing • 8. Leadership

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Root Causes – Medication Error 1995-2004

• 1. Communication• 2. Orientation / Training• 3. Competency / Credentialing• 4. Staffing• 5. Procedural Compliance• 6. Availability of Info• 7. Patient Assessment• 8. Environmental Safety; Security

& Leadership

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Root Causes – Medication Error 2005

• 1. Communication• 2. Procedural Compliance • 3. Competency / Credentialing• 4. Leadership; Patient

Assessment; Orientation / Training

• 5. Environ. Safety/Security• 6. Organizational Culture ;

Staffing

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Root Causes – Delay in Tx. 1995-2004

• 1. Communication• 2. Patient Assessment• 3. Continuum of Care• 4. Orientation / Training • 5. Availability of Info• 6. Competency / Credentialing• 7. Staffing • 8. Care Planning

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Root Causes – Delay in Tx. 2005

• 1. Communication• 2. Patient Assessment• 3. Procedural Compliance• 4. Continuum of Care /

Availability of Info• 5. Care Planning / Leadership• 6. Competency / Credentialing

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Root Causes – Patient Falls 1995-2004

• 1. Orientation/Training• 2. Communication• 3. Patient Assessment• 4. Environmental Safety /

Security• 5. Care planning• 6. Leadership & Staffing• 7. Competency / Credentialing• 8. Availability of Info

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Root Causes – Patient Falls 2005

• 1. Patient Assessment• 2. Communication• 3. Environmental Safety / Security• 5. Leadership • 6. Procedural Compliance• 7. Orientation / Training; Care Planning• 8. Availability of Info; Competency /

Credentialing

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Root Causes – Restraint Injury/Death 1995-2004

• 1. Orientation / Training• 2. Patient Assessment• 3. Communication• 4. Care Planning• 5. Staffing• 6. Competency / Credentialing & Availability of Info.• 7. Environmental Safety / Security• 8. Procedural Compliance• 9. Continuum of Care

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Root Causes – Restraint Injury/Death 2005

• 1. Communication; Patient Assessment

• 2. Environmental Safety / Security• 3. Orientation / Training;

Competency / Credentialing & Availability of Info.

• 4. Procedural Compliance; Care Planning

• 5. Leadership

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Now What?• Learn from Knowledge of:

– Sentinel Event Statistics– Root Causes

• Make Prevention a Priority– Make changes– Improve patient safety– Follow Joint Commission

recommendations•Sentinel Event ALERT

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Wrong Site Surgery Prevention

• Clearly mark the operative site and involve the patient in the process

• Require oral verification of the correct site in the OR by each member of the surgical team

• Develop verification checklist that includes all documents

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Wrong Site Surgery Prevention

• Surgical teams consider taking a “time out” to verify patient, site, procedure using active communication

• Ensure ongoing monitoring that verification process is followed

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Inpatient Suicide Prevention

• Identify/Remove/Replace non-breakaway hardware

• Weight test all breakaway hardware

• Revise procedures for contraband detection and include family and friends in process

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Inpatient Suicide Prevention

• Standardize suicide risk assessment/reassessment procedures

• Enhance staff orientation and education

• Ensure consistency in implementation of observation procedures

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Inpatient Suicide Prevention

• Redesign, retrofit, or introduce security measures

• Revise information transfer procedures

• Implement education for family and friends regarding suicide risk factors

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Op/Post-Op Complications Prevention

•Improve staff orientation and training

•Educating and counseling physicians

•Revising credentialing and privileging procedures

•Clearly defining expected channels of communication

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Op/Post-Op Complications Prevention

• Standardizing procedures across settings of care

• Revising the competency evaluation process.

• Monitoring consistency of compliance with procedures

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Op/Post-Op Complications Prevention

•Implementing a teleradiology program

•Correct placement of catheters and tubes should be verified with a test or x-ray

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Medication ErrorsPrevention

• Recognize High Alert Meds:– Insulin–Opiates and Narcotics– Injectable Potassium Chloride– Intravenous Anticoagulants–Sodium Chloride Solutions above 0.9%

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Medication ErrorsPrevention

• Follow the 5 (6) Rights of Medication Administration– Use 2 identifiers

• Limit and institute “Read Back” policy of all verbal orders

• Standardize Abbreviations

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Medication ErrorsPrevention

• Joint Commission abbreviations on the DO NO USE list:– U for Unit – write unit– IU for International Unit – write

international unit– QD, QOD – Write daily or every other

day

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Medication ErrorsPrevention

• Joint Commission abbreviations on the DO NO USE list:– Trailing zero (X.0 mg.) – write (X

mg.)– Lack of leading zero (.X mg) - write

(0.X mg) – MS, MSO4, MgSO4 - write morphine

sulfate, magnesium sulfate

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Medication ErrorsPrevention

• Expand the DO NOT USE list:– ug for microgram – write mcg.– H.S. – write out half strength or at

bedtime– T.I.W. – write 3 times weekly– S.C. of S.Q. – write Sub-Q or subQ– D/C – write discharge or discontinue– cc. – write ml.

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Medication ErrorsPrevention

• Remove Potassium Chloride/Phosphate from floor stock

• Standardize and limit drug concentrations

• Move drug preparation off units and use commercially available premixed IV solutions

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Medication ErrorsPrevention

• Do not store heparin and insulin next to each other

• System plan for sound alike and look alike meds

• Educate staff about hydromorphone and morphine

• Implement PCA protocols that involve double-checks of drug, pump setting and dosage

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Medication ErrorsPrevention

• Use only IV pumps with set-based free flow protection

• Limit the variety of pumps available in the organization

• Provide or ask for both brand and generic names of drugs for medication orders

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Medication ErrorsPrevention

• Provide the generic and brand name on all medication labels

• Provide the patient with written information about their drugs which includes the brand and generic names

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Medication ErrorsPrevention

• Patient controlled analgesia by proxy– Develop criteria for selecting

appropriate patients to receive PCA– Carefully monitor patients– Teach staff, patients and family

members about dangers of pressing button for patient

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Medication ErrorsPrevention

• Using medication reconciliation to prevent errors– Process for obtaining and

documenting complete list of current medications on admission/transfer/discharge

– Create a process for reconciling medications at all interfaces of care

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Delay in TreatmentPrevention

• Implement processes and procedures designed to improve the timeliness, completeness and accuracy of staff-to-staff communication

• Implement face to face interdisciplinary change-of-shift debriefings

• Reduce verbal orders and require “read-back” policy

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Patient FallsPrevention

• Standardize Assessment of Risk for Falls

• Ongoing reassessment regarding risk

• Orient staff to formal fall prevention protocols

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Restraint Injury/DeathPrevention

• Redouble efforts to reduce use of physical restraints

• Enhance staff education regarding alternatives to physical restraints

• Develop structured procedures for consistent application of restraints

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Restraint Injury/DeathPrevention

• Continuously observe patients in restraints

• If patient is restrained in supine position, ensure head is free to rotate and HOB is elevated.

• Do not restrain a patient in bed with unprotected split side rails

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Creating a Culture of Safety

• Understand human factors and system flaws

• Make safety everyone’s responsibility

• Report errors or near misses to decrease future error

• Actively seek improvement to process

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Creating a Culture of Safety

• Know and understand the six major categories of negligence:– Failure to follow standard of care– Failure to use equipment in proper,

responsible manner– Failure to communicate, including

inadequate transfer of information

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Creating a Culture of Safety

• Know and understand the six major categories of negligence:– Failure to document properly– Failure to accurately assess and

monitor– Failure to act as an advocate for the

patient

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Patient Responsibilities• Be an active member of the

healthcare team• Make sure doctors know about all

medicines you are taking• Make sure doctors know about your

allergies or adverse reactions• When the doctor writes a prescription

be sure you can read it

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Patient Responsibilities

• Ask for information about your medicine that you can understand

• When pick up medicine from pharmacy, ask if this is the medicine your doctor prescribed

• If you have any questions about the directions, ask!

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Patient Responsibilities

• Choose a hospital at which many patients have had the surgery or procedure you need

• Ask care providers if they have washed their hands

• Prior to surgery, make sure that you, your doctor and your surgeon all agree on what is to be done

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Patient Responsibilities

• Speak up if you have questions• Ask a family member or friend to

be there with you to be your advocate

• Learn about your condition and treatments by asking your doctor and using other reliable resources

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2007 National Patient Safety Goals

• Improve the accuracy of patient identification

• Improve the effectiveness of communication among caregivers

• Improve the safety of using medications

• Reduce the risk of health care-associated infections.

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2007 National Patient Safety Goals

• Accurately and completely reconcile medications across the continuum of care

• Reduce the risk of patient harm resulting from falls

• Reduce the risk of influenza and pneumococcal disease in institutionalized older adults

• Reduce the risk of surgical fires

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2007 National Patient Safety Goals

• Implementation of applicable NPSG and associated requirements by components and practitioner sites

• Encourage patients’ active involvement in their own care as a patient safety strategy

• Prevent health care-associated pressure ulcers

• The organization identifies safety risk inherent in its patient population.