Patient_Safety - Medication errors and patient safety and...

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Unformatted text preview: Medication errors and patient safety and Vic Vernenkar, D.O. Department of Surgery St. Barnabas Hospital Quality in Healthcare Quality Begins with ensuring patient safety Patient safety Patient Freedom from injury or illness resulting from Freedom the processes of healthcare the Healthcare errors Healthcare Top worry of patient! Healthcare errors Healthcare Failure to diagnose / incorrect diagnosis Failure to utilise or act on diagnostic Failure tests tests Inappropriate use or outmoded Inappropriate diagnostic tests / treatments diagnostic Failure to monitor or provide follow-up Wrong site surgery, medication errors Wrong medication Transfusion mistakes Healthcare errors Healthcare Nosocomial infections Patients falls Pressure sores Phlebitis associated with intravenous Phlebitis lines lines Restraint related strangulation Preventable suicides Failure to provide prophylaxis How big is the problem? How USA errors by HCWs affect about 3-4% patients • • • • mean of 7% ADEs >7,000 ADE deaths / year 2 million nosocomial infections / year average ICU patient experiences almost 2 errors per day each year, 44,000 - 98,000 deaths due to medical each errors annual cost of medical errors: US$29 billion Medication errors Medication Prescribing errors Administration errors iincludes failure to monitor drug levels and ncludes side effects of treatment side Medication errors Medication Rate of 3.99 per 1000 medication orders (Albany, NY, Rate USA) USA) a third had potential to cause adverse events Common factors failure to take account of declining renal/hepatic function failure to check for possible allergic responses using wrong drug name or means of administration miscalculation of dosage prescribing an unusual critical frequency of dose prescribing Lesar et al. Factors related to medication errors. JAMA 1997; 277: 312-7 Why did it happen? Why Technology e.g. infusion pumps Many care-givers High acuity of illness / injury Environment prone to distraction Time-pressured, need to make quick Time-pressured, decisions decisions High volume, unpredictable patient load Key reasons Key Patients are more at risk than non-patients Medical interventions are, by their nature, Medical high-risk procedures - small error margins high-risk Medicine remains an inexact, hands-on Medicine endeavour endeavour Errors are inevitable ………….but most are preventable Facts Facts Often it is the best people who make the Often worst errors worst About 90% of errors are not culpable But some people knowingly adopt But behaviors more likely to produce error substance abuse, long working hours substance Organisational accident model Organisational Organisational and corporate culture Management decisions and organisational processes James T Reason Contributory factors influencing clinical practice Task Error producing conditions Errors Violation producing conditions Violations Defence barriers Accident or incident Process review and change Process Whose job is it? - Risk Manager? Lessons from past Lessons Problems often formally recognised when there Problems is a major incident major Methodologies for organisational analysis not Methodologies organisational well developed well Short-term corrective action not well sustained Short-term not Problems in dealing with aftermath of service Problems aftermath failure - grievance of victims and their families failure Cycle of prevention Failure in standard of care Prevent similar problem Detect Deal with consequences Sustain corrective action Take corrective action Analyse Recommendations Recommendations Leadership priority Clear organisational commitment to Clear patient safety (infrastructure and resources) resources) No-blame culture Culture of safety Culture Integrated pattern of behaviour Underlying philosophy and values Continuos search to minimise hazards and Continuos patient harm patient Culture of safety Acknowledges high risk, error prone Acknowledges nature nature Widespread shared acceptance of Widespread responsibility for risk reduction responsibility Open communication about safety Open concerns, non-punitive environment concerns, Reporting of errors and safety concerns Culture of safety Learns from errors Accountability for patient safety Organisational structure, processes, Organisational goals and rewards aligned with improving patient safety improving Strategy 1: teams Strategy Implement known safe Implement practices practices Design work so that it is Design easy to do it right and hard to do it wrong hard Reduce reliance on Reduce memory memory Less steps Constraints Protocols and checklists Clinical Pathways Care process models Teams - lessons from the navy Teams Members monitor each other’s performance and Members stepped in to to help out. TRUST was an implicit TRUST part of this. part Giving and receiving feedback was norm for all Giving team members. Understanding each other’s role is important part. role Communication was made real: senders checked their messages were received as intended. intended. Teamwork and team leadership Teamwork Good teams do not develop on their own organisational culture of welcoming openness organisational and monitoring changes that result and Good team leadership is essential development is vital across organisation Hospital team activities Hospital Improving information access Standardising and simplifying medication procedures teams worked on high risk and high error-potential drugs Restricting physical access to potentially lethal drugs hospital teams redesigned medication administration records chemotherapy drugs, concentrated KCl, NaCl Educating clinical staff about medications to assess knowledge deficiencies, drug knowledge, awareness to for potential for error for Silver et al. Reducing medication errors in hospitals: a peer review organisation collaboration. J Qual Improvement 2000; 26: 332-40 Strategy 2: education Strategy Recognise effect of Recognise fatigue on performance performance Education and Education training for safety training Teamwork Reduce known Reduce sources of confusion sources Awareness Awareness Education Training and supervision Training Training in organisational aspects of care medical training focuses on diagnosis and medical management of individuals management Training in skills of risk management understanding of inevitability of human error factors associated with errors, mistakes and near factors misses misses appropriate checking behaviour, safe handover team work Strategy 3: accountability Strategy Acknowledge error Apologise Provide remedial care Conduct root cause Conduct analysis analysis Fix system or process Fix problems problems Risk management Risk system system Sentinel event team Clinical incident reporting system system Success depends on change in culture staff must be convinced of importance of staff patient safety patient board has to agree on “no-blame” culture systematic and strategic approach to risk systematic management management reporting system must produce reports that reporting are timely and informative are Main Incident Page – Reporting Person Risk Management Risk Management System (RMS) Fall Report Fall Report Sharp Report Reporting Nurse Fall Report Sharp Report Nurse Manager Sharp Report Supervisor / Manager Sharp Report Follow-up Doctor Assist. Director Nursing Sharp Report Injured Staff Fall Report Sharp Report Sharp Report Sharp Report Sharp Report Fall Report Reporting Doctor Medication Error Report Reporting Person CMB / Administrator Doctor Management Medication Error Report Pharmacy Manager CEO/CMB Head of Department / Division Chairman Dept Of Quality Management Medication Error Report Infection Control (Sharp only) M e d ic a tio n e rro rs S h a rp s in ju ry C lin ic a l in c id e n t: m o r b id ity m ro ta lity s u rg ic a l in c id e n t P a tie n t fa lls RM S Risk Management System C at I C M B a n d D Q M in fo rm e d w ith in 6 H SET R o o t c a u s e a n a ly s is b y a p p o in te d te a m C a t I o r C a t II? C a t II R e p o rt w ith in v e s tig a tio n fin d in g s a n d re c o m m e n d a tio n s to D iv is io n C h a irm a n R e p o rt to C M B , C E O , a n d D Q M R e c o m m e n d a tio n s re p o rte d to S E T H O D /M a n a g e rs m o n ito r to a s s u re c o m p lia n c e w ith c o rre c tiv e a c tio n s a n d re p o rt b a c k to R M Y es R e c o m m e n d a tio n s im p le m e n te d ? No O p e ra tio n s in fo rm e d to im p le m e n t re c o m m e n d a tio n s D Q M p re s e n ts fin d in g s , re c o m m e n d a tio n s , s u m m a ry a n a ly s is , a n d fo llo w -u p to R M , Q C , re p o rts n u m b e r o f e v e n ts q u a rte rly p e r d e p a rtm e n t to Q C a s p a rt o f B S C C o m p la in ts Sentinel Event Team Sentinel CEO CMB Administrator, Nursing Director, QM Administrator, Medical Board Sentinel Event Team Sentinel Incident reporting, complaints Category I SET discussion Appoints team to investigate Root cause analysis Root Reviewing the process What happen? How did it happen? Why did it happen? What can we do differently? MOH requirement MOH Report within 7 days of knowing Submit full report within 60 days De-identify Objective: how can we improve what happen, how did it happen, why did it what happen, can we do differently? happen, Impact Impact “As evidence in support of the value of the changes made to our processes, we observed no further fatal ADEs…..” John Rex et al. Systematic root cause analysis of adverse drug events in a tertiary referral hospital. J Qual Improvement 2000; 26: 563-75 Key findings in IOM report: Key findings in IOM report: • Errors occur because of system failures • Preventing errors means designing safer systems of care Committee on Quality of Health Care in America. To Err is Human. Institute of Medicine, 2000. IOM report IOM Avoid reliance on memory Use constraints or forcing functions Avoid reliance on vigilance Simplify key processes Standardise work processes Institutional practice Institutional Clinical risk management system Plan Process People Culture LEADERS ...
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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