Saeid Eslami s.eslami@amc.uva.nl. Errors and ADEs are costly Adverse Events in USA Hospitals: 80,000 people hospitalised/year 7,000 deaths/year. 50% of.

Saeid Eslami

s.eslami@amc.uva.nl

Errors and ADEs are costlyAdverse Events in USA Hospitals:

80,000 people hospitalised/year

7,000 deaths/year.

50% of these errors definitely or possibly preventable

$22 billion, costs of preventable adverse events

(1999 USA Institute of Medicine Report)

Errors and ADEs are costlyAt least 1.5 million preventable

ADEs occur each year in the US:

Hospital: 380,000-450,000. Ambulatory Care: 530,000 Long-term care: 800,000

Cost of ADE Non-preventable ADE: $2,595 Preventable ADE: $4,685

Bates DW et al . JAMA. 1997

خبر خوب، من موبایلمو پیدا

!کردم

خبر بد، رو !!ویبراتور بوده

In Holland (2005): Each year 10,000 people receive wrong medication

and more than 3000 death each year because of errors.

In Australia:Medical error results in as many as 18 000

unnecessary deaths, and more than 50 000 patients become disabled each year.

AU$ 5 Billion (AUS)

Errors and ADEs are costly

Medication Errorsnearly 1 of every 5 doses in the typical hospital and

skilled nursing facility.The percentage of errors rated potentially harmful was

7%, or more than 40 per day in a typical 300-patient facility.

The problem of defective medication administrations systems, although varied, is widespread.

Medication Errors Observed in 35 Health Care Facilities Kenneth N. Barker, PhD; Elizabeth A. Flynn, PhD, et al. (REPRINTED) ARCH INTERN MED/VOL 162, SEP 9, 2002 2002 American Medical Association

Adverse Events -International information

Baker et al, Canada 2000Thomas et al, Utah Colorado

1992Wilson et al,* Australia, 1995Thomas et al, 2000, reworked

1995 Australian dataBrennan et al, Leape et al, New

York 1984Vincent et al, London 1999,2000Davis et al*, New Zealand 1998

AE’s Preventable7.5% 36%

2.9% --

16.6% 51%

10.6% --

3.7% --

10.8% 48%

12.9% 37%

* Slight to modest evidence of healthcare management causation = 2 out of 6 scale, other papers management causation more certain:- 4 out of 6 scale

Source – The Philadelphia Inquirer

The(US) National Burden of Systemic Errors in the Health Care

More than 3 fully occupied Jumbo jets of the Health Care Industry drop out of the sky every day ! (Adapted from Leape:

the Patient Safety Guru of USA)

And then there are other adverse Events!!

US H

ealthcare

In 2001 there were 4.3 millionambulatory visits for treating Adverse Drug Events Zhan et al 2005

How Hazardous Is Health Care?How Hazardous Is Health Care?(Modified from Leape)(Modified from Leape)

1

10

100

1000

10000

100000

1 10 100 1000 10000 100000 1000000 10000000

DangerousDangerous

(>1/1000)(>1/1000)

RegulatedRegulated Ultra-Ultra-SafeSafe

(<1/100(<1/100K)K)

HealthCare

Bungee Jumping

Mountain Climbing

Driving

Chemical Manufacturing

Chartered Flights

Scheduled Airlines

European Railroads

Nuclear Power

Numbers of encounter for each fatalityNumbers of encounter for each fatality

Tota

l li

ves

lost

per

year

Tota

l li

ves

lost

per

year

………Patient safety defined as freedom from accidental injury due to medical care…..Institute of Medicine. To Err is Human. Building a safer Health System, Washington, National Academy Press: 1999

An adverse events: harm or injury caused by the management of a patients’ disease or condition by health care professionals rather than by the underlying disease or condition itself……The World Health Profession Alliance

Definitions:

Definitions:Sentinel Event

An unexpected occurrence involving a death or serious physical or psychological injury or risk thereof. Serious injury specifically includes loss of limb or function.

Preventable Adverse EventCould/should not have happened (Error)

Non-Preventable Adverse EventCould not have been predicted or foreseen

Potential Adverse Event“Near miss” or “close call”, could have resulted in an

accident, injury or illness, but did not, either by chance or through timely intervention

Errorthe failure of a planned action to be completed as intendedthe use of a wrong plan to achieve an aim.

11

Errors Types (another classification)

G and R Singh

Overusein 2001 top 50 medical and surgical procedures numbered 42 million. 7.5 million of these were unnecessary surgical procedures – causing about 40,000 deaths.

UnderuseMuch greater problem than Overuse. Patients failed to receive recommended care about 46% of the time. e.g. hypertension receives 65% of recommended care.

MisuseAbout 11% of the time patients receive care not recommended – leading to harm

Medical Errors & Adverse Events

13

Medical ErrorsAE

Preventable AE

Non-preventable

NearMiss

Serious Medical Errors

A, R & G Singh 2002

Advances in medical knowledge required to prevent

recurrence

Patient’s Encounter with Health Care System

No error occursIF

Unavoidable adverse event

occurs

OU

TC

OM

EA

CT

ION

R

QD

Opportunities for system redesign and improvement – commonly go

unnoticed

Beneficial outcome may occur

IF

System redesign and improvement

required to prevent

recurrence

Patient’s Encounter with Health Care System

IFError occurs

Consequential

Preventable adverse event

occurs

IF

OU

TC

OM

EA

CT

ION

R

QD

A, R & G Singh 2002

Opportunities for system redesign and improvement – commonly go

unnoticed

Patient’s Encounter with Health Care System

IFError occurs

Inconsequential on its own

Beneficial outcome may occur

IF

OU

TC

OM

EA

CT

ION

R

QD

A, R & G Singh 2002

System redesign and improvement

required to prevent

recurrence

Patient’s Encounter with Health Care System

IFError occurs

IF

Inconsequential on its own

IF

Preventable adverse event

occurs

Undetected(may causecascade of

errors)

IF

OU

TC

OM

EA

CT

ION

R

QD

A, R & G Singh 2002

System redesign and improvement

required to prevent

recurrence

Advances in medical knowledge required to prevent

recurrence

Opportunities for system redesign and improvement – commonly go

unnoticed

Patient’s Encounter with Health Care System

No error occursIF

Error occurs

IF

ConsequentialInconsequential on its own

IF

Detected and corrected

Preventable adverse event

occurs

Undetected(may causecascade of

errors)

Beneficial outcome may occur

Unavoidable adverse event

occurs

IF

IF OU

TC

OM

EA

CT

ION

R

QD

OU

TC

OM

EA

CT

ION

R

QD

A, R & G Singh 2002

IsordilorPlendil?

Other Example:

-Glucose-Oxygen/CO2

What shall manager do?How can we prevent them?

• Underestimated by a factor of 20 or greater

• Reports in health care would presumably number in the millions if adverse events, no harm events, and near misses were captured.

Agency for Healthcare Research and Quality, Making Health Care Safer: A Critical Analysis of Patient Safety, July 2001 Donald Holmquest, MD, PhD, JDChief Technology Offices, eMedical Research, Inc. – 3000 medical fatal errors for 1,000,000 people

More Common than We Thought

Richard Smith

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

Wolfgang von Goethe

How to think of error?An individual failing

It will not solve the problem--it will probably in fact make it worse because it fails to address the problem

Doctors will hide errorsMay destroy many doctors inadvertently (the second

victim)A systems failure

This is the starting point for redesigning the system and reducing error

James Reason’s bottom lineFallibility is part of the human condition

We can’t change the human condition

We can change the conditions under which people work

• Historically, mistakes or poor outcomes have been blamed on “dumb doctor,” or “dumb nurse.” The “solution” was the ABP reaction – Accuse, Blame and Punish.

• But inefficiencies and errors mostly can be traced not to one error, but a cascade of poor or poorly executed procedures, policies, technologies and training. A good system will provide a good outcome; a poorly designed one will produce a poor one.

•We need to design health care systems that put safety first (First, do no harm)

Hopkins Medical News, Edward D. Miller, M.D., Fall 2002, Page 56

Good Outcomes, Good Systems

“…adverse events are generally not the result of one thing that went wrong. They result from the combination of a series of latent errors that are built into the system.”

Paul M. Schyve, MD, Vice President, JCAHO In: Reducing Medical Errors, Improving Patient Safety: Taking the Next Step, HealthLeaders Roundtable, June 2001.

A System Problem

SAFETY BARRIERS

Theory of Constraints

Any improvement is a changenot every change is an improvement

but we cannot improve something unless we change it

Goldratt (1990)

any change is a perceived threat to securitythere will always be someone who will look at the

suggested change as a threat

any threat to security gives rise to emotional resistanceyou can rarely overcome emotional resistance with logic

aloneemotional resistance can only be overcome by a stronger

emotionGoldratt (1990)

Any improvement is a change

“Anyone who thinks you can overcome

emotional resistance with logic was probably

never married”

Panic Zone•peopleclose up•they freeze•they don’t learn

Comfort Zone•people stay here•they don’t learn

•they don’t change

Discomfort Zone

Comfort Zone

PanicZone

•uncertainty•learning

“Tell me and I will forget

Show me and I may remember

Involve me and I will understand”

In comparison with:“See oneDo one

Teach one”

Emotionally, Intellectually and physically

BUT Excluding the EGO

i.e. HALO!

It is important to be aware of:

19-04-23 39

Involve the nurses

4 equally important parts of improvement

Process and systems thinking

Making it a habit: initiating, sustaining

and spreading improvement in

daily work

Involving users, carers, staff and

the public

Personal and organisational development

Vision: Every single person is capable, enabled and encouraged to work with others to improve their part of the service

Discipline of improvement in health and social care (Penny 2003)

Hospital standardised mortality rates by reference costs

50

60

70

80

90

100

110

120

130

140

50 60 70 80 90 100 110 120 130

Reference costs 2002

HS

MR

200

2

Source: ‘Pursuing Perfection’ programme

No relationship between cost and mortality

in UK

-Glucose-Oxygen/CO2

What shall manager do?How can we prevent them?

Safety Principles

Error prevention Making errors visible Mitigation of harm from errors

“No problem can be solved within the same consciousness which caused it.”

Albert Einstein

“Since modern information tools can do things that the unaided human mind cannot do, when we use such tools we may see a picture of medicine we have not seen before.”

Larry Weed

“…there are enormous ‘voltage drops’ along the transmission line for medical knowledge.”

Lawrence Weed (1997)

Safety in Flying1903 First Powered Flight1908 First Pilot dies1910 First mid-air collision1918 31 of first 40 US Air Mail pilots

die in crashes1994 4 crashes/10,000,000 takeoffs

45

Flight vs. HealthcareMachine vs. Human (Flight)Human vs. Human (Healthcare)

“A growing body of evidence supports the conclusion that various types of IT applications lead to improvements in safety… Nonetheless, IT has barely touched patient care.”

Source: IOM, Crossing The Quality Chasm, p. 187.

Information Technology

Information Technology to Improve Patient Safety

Electronic medical records (EMR)Electronic orders and prescribing:

Computerized Physician Order Entry (CPOE)Electronic decision-support toolsHandheld devices (PDAs) The electronic office

Technology has Become a Preferred Solution by Many Groups:

IOM reports

Leapfrog

ISMP

Media

Legislators

50

Order____________________________________

Point o f Care

?

N atriumKaliumCalciumM agnesiumASATALATalkPa segam m aG T

?

Point of Care

CPOEWatchdog• renal failure?• special dose requirements?• Contraindications?

Dose calculation• single dose• dosing intervall• divisibility

1 2

3

Drug data base• local formulary• common thesaurus

• Create a clinical data repository consolidation key clinical data• From this database, information can be located efficiently and reliably

Generation I = 15% reduction in preventable errors

Generation I

• Implementation of basic clinical decision support systems (CDSS) - a key for eliminating errors

GI (15%) + GII (25%) = 40% reduction in preventable errors

Generation II

Reducing Haphazard Decisions

How fast can Igive this drug ?

Where are the chart & blue card ?

Is there apolicy ?

What’s the lastPotassium ?

What does this child weigh ?

What’s the doseof potassium ?

Protection from Overdose?

… for example sedation

Midazolam (Dormicum®)

• sedative before interventions (e.g. dental or other surgery, endoscopy)

• sedation in respirator therapy

• emergency treatment of epileptic fits (e.g. status epilepticus)

Adults

Children

Clin

Pha

rmac

okin

et 9

8;35

:37

Midazolam clearance

0.1

0.2

0

0.3

0.4

0.5

0.6

0.7

L/h/kg

Born 4 8 12 16 20Year

Adults

Children

Midazolam distribution

Clin

Pha

rmac

okin

et 9

8;35

:37

0.25

0.5

0

0.75

1

1.25

1.5

1.75

L/kg

Born 4 8 12 16 20Year

2

Adults

Children

Underdosing

Overdosing

Midazolam dosing according to weight

Year

1

2

0

3

4

5

6

Born 4 8 12 16 20

Renal failure: risk without dose adjustmentIrreversible cerebellar damage

Coma, epileptic fits

Confusion

Arrhythmia, K+

Grandmal

AV-Block

Con

cent

ratio

n in

ren

alfa

ilure

2*

4*

6*

8*

10*

0.5*

D igoxin, I m ipenem

Aciclovir, Cefuroxim e

Lithium

N orm al 75 50 25Renal function

D ialysis

Bisopro lo l

Ranitid ine

Baseline M etopro lo l

Drug-Drug Interaction

10 combinations

45 combinations

5 drugs

10 drugs

• Combining CDSS across the continuum of care (in and out patients)• Use of controlled medical vocabulary to normalize medical concepts• CPOE (to better manage ordering)• Work flow improvements• Combining work flow change and CDSS• This 3rd generation has the basic infrastructure to measure or asses incidence of potential errors and measure effectiveness of interventions

GI (15%) + GII (25%) + GIII (30%) = 70% preventable error. IOM goal of at least a 50% reduction of preventable medical

errors

Generation III

Errors resulting in ADEs: Harvard Study

56%34%

6% 4%

Ordering

Administration

Transcription

Dispensing

64

Bates DW et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995;274:29-34.

eMAR & Bar-coding

CPOE

خوب! راحت باش و روی

بارکدخوان دراز !بکش

• More sophisticated CDSS• Tailored care to the individual patient• Disease management tracking• Protocols (Care management, Clinical)•GI (15%) + GII (25%) + GIII (30%) + GIV (20%) = 90%

preventable error.

Generation IV

After the next decade 2010

•Highly sophisticated CDSS•True evidence-based medicine•Outcomes tracking of each episode of care•Links to NLM and new medical research results from the medical literature•Interfaces to mobile personal monitoring devices•Personalized accessible patient record information anywhere

Generation IV

PEDIATRICS Vol. 116 No. 5 November 2005The Introduction of Computerized Physician Order Entry and Change

Management in a Tertiary Pediatric Hospital

Jeffrey S. Upperman MD; Patricia Staley BA; Kerri Friend BA; Jocelyn Benes RN; Jacque Dailey RNWilliam Neches MD; and Eugene S. Wiener MD

From the Departments of Surgery, Quality and Care Management, and Cardiology, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania

Conclusion. CPOE is an invaluable resource for supporting patient safety in health care settings.

PEDIATRICS Vol. 116 No. 6 December 2005 Unexpected Increased Mortality After Implementation of a Commercially

Sold Computerized Physician Order Entry System

Yong Y. Han, MD; Joseph A. Carcillo, MD; Shekhar T. Venkataraman, MD; Robert S.B. Clark, MD; R. Scott Watson, MD, MPH; Trung C. Nguyen, MD; Hülya Bayir, MD; and Richard A. Orr, MD

From the Departments of Critical Care Medicine and Pediatrics andClinical Research, Investigation and Systems Modeling in Acute Illness

(CRISMA) Laboratory, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania

Conclusion. We have observed an unexpected increase in mortality coincident with CPOE implementation.

وووه! االن تصادف می

! ... کنم

No. of years for 30% of Americans to own technology:• Telephone 40 years• Television 17 years• PC 13 years• Internet 7 years

D.Z. Sand, HIMSS presentation 2002, Cambridge Technology Partners

Technology Adoption, Change!

“Physicians had always avoided applying mathematics to the study of the body or disease. In the 1820’s, 200 years after the discovery of thermometers, French clinicians began using them.”

The Great Influenza, John M . Barry p25

Thermometers

• Physicians were taught to be independent and have been resistant to guidelines and systems• Physicians view teamwork as golf teams not volleyball teams• Disruptive behavior has been tolerated and in some respects rewarded among physicians

Main Barriers

،مطالعه در حوزه امنیت پزشکی همانند الیه الیه کردن پیاز است،هرچه بیشتر ادامه می دهید بیشتر پیدا می کنید

!و بیشتر گریه می کنید

Point of Care