patient safety issues where does the lab professional fit in? mary ann mclane, phd, cls(nca) region...
TRANSCRIPT
Patient Safety Issues
Where Does the Lab Professional Fit In?
Mary Ann McLane, PhD, CLS(NCA)Region II Director
The patient must come
first!
Objectives
At the conclusion of this seminar, the participant will be able to:
Describe the components of the Institute of Medicine’s 1999 “To Err Is Human” document which relate to the clinical lab.
Compare and contrast the programs offered by JCAHO’s Speak Up” initiative.
List at least 5 examples of errors involving patient safety and pre-analytical/post-analytical error.
Unsafe acts are like mosquitoes…
You can try to swat them one at a time, but there will always be others to take their place. The only effective remedy is to drain the swamps in which they breed. In the case of errors and violations, the "swamps" are equipment designs that promote operator error, bad communications, high workloads, budgetary and commercial pressures…
Unsafe acts are like mosquitoes…
…procedures that necessitate their violation in order to get the job done, inadequate organization, missing barriers, and safeguards . . . the list is potentially long but all of these latent factors are, in theory, detectable and correctable before a mishap occurs.
James Reason, To Err Is Human
Americans harmed by medical error
Two studies of large samples of hospital admissions New York using 1984 data Colorado and Utah using 1992 data
adverse event (injuries caused by medical management) were 2.9 and 3.7 percent respectively
adverse events attributable to errors (i.e., preventable adverse events) was 58 percent in New York, and 53 percent in Colorado and Utah
extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997 44,000 to 98,000 Americans die in
hospitals each year as a result of medical errors
exceed the number attributable to the 8th-leading cause of death
exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516)
Total national costs
lost income, lost household production, disability, health care costs $37.6 billion to $50 billion for adverse
events $17 billion to $29 billion for preventable
adverse events slightly higher than the direct and indirect
costs of caring for people with HIV and AIDS.
Lives lost
more than 6,000 Americans die from workplace injuries every year
in 1993 medication errors are estimated to have accounted for about 7,000 deaths one out of 131 outpatient deaths one out of 854 inpatient deaths
Medication-related errors occur frequently in hospitals; not all result in actual harm, but those that do are costly. 2% admissions at two large hospitals:
preventable adverse drug event average increased hospital costs of $4,700
per admission about $2.8 million annually for a 700-bed
teaching hospital.
Medication-related errors not all result in actual harm those that do are costly Preventable: $2 billion for the nation
as a whole.
Not just hospital patients
In 1998: ~2.5 billion prescriptions were dispensed by U.S. pharmacies at a cost of about $92 billion. errors in
prescribing medications dispensing by pharmacists unintentional nonadherence on the part
of the patient.
Definitions
Adverse event injury caused by medical
management rather than the underlying condition of the patient.
Preventable adverse event adverse event attributable to error
Definitions
Error the failure of a planned action to be
completed as intended (i.e., error of execution)
the use of a wrong plan to achieve an aim (i.e., error of planning)
Definitions
Negligent adverse event the care provided failed to meet the
standard of care reasonably expected of an average physician qualified to take care of the patient
Discussion point: expected of an “average physician” only?
Why focus on medication-related error?
One of the most common types of error
Substantial numbers of individuals are affected
Accounts for a sizable increase in health care costs
Why focus on medication-related error? Easy to identify an adequate sample of
patients who experience adverse drug events
The drug prescribing process provides good documentation of medical decisions, residing in automated, easily accessible databases Case of Comfort and Caring, Inc
Deaths attributable to medication errors are recorded on death certificates.
Important note!
“There are probably other areas of health care delivery that have been studied to a lesser degree but may offer equal or greater opportunity for improvement in safety.”
That is us!!
What the literature shows
1. How frequently do errors occur?2. What factors contribute to errors?3. What are the costs of errors?4. Are public perceptions of safety in health care consistent with the evidence?
Harvard Medical Practice Study
>30,000 randomly selected discharges
51 randomly selected hospitals in New York State in 1984 Adverse events, manifest by prolonged
hospitalization or disability at the time of discharge or both = 3.7%
Preventable adverse events = 58% Negligence = 27.6%
Harvard Medical Practice Study 13.6% resulted in death 2.6% caused permanently disabling
injuries
Type of adverse event drug complications = 19% wound infections = 14% technical complications = 13%
First instinct?
Blame someone! However… due most often to the
convergence of multiple contributing factors
blaming an individual does not change these factors and the same error is likely to recur
Case of Charles Thompson, deathrow inmate from TX
What would work better? Preventing errors and improving safety
for patients requires a systems approach to modify the conditions that
contribute to errors which recognizes people working in
health care are among the most educated and dedicated workforce in any industry
What would work better? The problem is not bad people The problem is that the system
needs to be made safer.
Hindsight bias
things that were not seen or understood at the time of the accident seem obvious in retrospect misleads a reviewer into simplifying the
causes of an accident highlighting a single element as the
cause overlooking multiple contributing
factors
Hindsight bias
things that were not seen or understood at the time of the accident seem obvious in retrospect information about an accident is spread
over many participants no one may have complete information easy to arrive at a simple solution or to
blame an individual, but difficult to determine what really went wrong.
More definitions Slips
action conducted is not what was intended observable
Mistakes the planned action is wrong
More definitions Slips
physician chooses an appropriate medication, writes 10 mg when the intention was to write 1 mg
Mistakes selecting the wrong drug because the diagnosis
is wrong Important not to equate slip with "minor."
Patients can die from slips as well as mistakes.
Lab definitions? Slips (action conducted is not what was intended)
physician chooses an appropriate medication, writes 10 mg when the intention was to write 1 mgaaaaaaaaaaaaaaaaaaaaaaaaaaaa
Mistakes (the planned action is wrong)
Safety = absence of errors? More! Multiple dimensions
an outlook: health care is complex and risky and solutions are found in the broader systems context;
a set of processes: identify, evaluate, and minimize hazards and continuously improve
an outcome: manifested by fewer medical errors and minimized risk or hazard
Safety definition
Freedom from accidental injury from the patient's perspective, the
primary safety goal is to prevent accidental injuries
Safe environment = low risk of accidents reduce defects in the process or departures
from the way things should have been done establish operational systems and processes
that increase the reliability of patient care.
Active vs. latent error
Active errors occur at the level of the frontline operator their effects are felt almost immediately
Latent errors removed from the direct control of the
operator poor design, incorrect installation, faulty
maintenance, bad management decisions, and poorly structured organizations
Active vs. latent error
Active errors the pilot crashed the plane
Latent errors a previously undiscovered design
malfunction caused the plane to roll unexpectedly in a way the pilot could not control and the plane crashed
Active vs. latent error Latent error
greatest threat to safety in a complex system
often unrecognized have the capacity to result in multiple types
of active errors. Challenger accident traced contributing
events back nine years Three Mile Island accident, latent errors
were traced back two years
Active vs. latent error
Latent error difficult for the people working in the
system to notice errors may be hidden
in the design of routine processes in computer programs
in the structure or management of the organization
people become accustomed to design defects and learn to work around them, so they are often not recognized
Active vs. latent error
Latent error "normalization of deviance"
small changes in behavior became the norm
additional deviations became acceptable the potential for errors is created
signals are overlooked or misinterpreted signals accumulate without being noticed
Active vs. latent lab error
Active errors
Latent errors
First instinct? focus on the active errors by punishing
individuals (e.g., firing or suing them) retraining or other responses aimed at
preventing recurrence of the active error punitive response may be appropriate in
some cases (e.g., deliberate malfeasance) it is not an effective way to prevent
recurrence
First instinct?
Large system failures latent failures coming together in
unexpected ways appear to be unique in retrospect
Same mix of factors is unlikely to occur again efforts to prevent specific active errors
are not likely to make the system any safer
Focus on active errors
lets the latent failures remain in the system
their accumulation actually makes the system more prone to future failure
Focus on latent errors
Discovering and fixing latent failures, and decreasing their duration, are likely to have a greater effect on building safer systems than efforts to minimize active errors at the point at which they occur
likely to have a greater effect on building safer systems
High reliability theory
accidents can be prevented through good organizational design and management an organizational commitment to safety high levels of redundancy in personnel
and safety measures strong organizational culture for
continuous learning and willingness to change
Correct performance and error "two sides of the same coin”
Complexity and tight-coupling
Systems that are more complex and tightly coupled are more prone to accidents and have to be made more reliable complex and tightly coupled systems
can "spring nasty surprises.“ Guess what type of system
healthcare is????!!!
Two cases of success
Aviation Occupational health
growing awareness of safety concerns and the need to improve performance
comprehensive strategies creation of a national focal point for leadership development of a knowledge base dissemination of information throughout the
industry
Two cases of success
Aviation Occupational health
designated government agency with regulatory responsibility for safety
carefully constructed research agenda
substantial resources devoted to these initiatives
Third case of success?
Healthcare no cohesive effort to improve safety in
health care resources devoted to enhancing and
disseminating the knowledge base are wholly inadequate
“health care is not likely to make significant safety improvements without a more comprehensive, coordinated approach.“
Center for Patient Safety
provide leadership for safety improvements throughout the industry
establish goals and track progress in achieving results
expand the knowledge base for improving safety in health care
provide visibility to safety concerns
Role of professionals Become active leaders in encouraging and
demanding improvements in patient safety. Setting standards, convening and
communicating with members about safety Incorporating attention to patient safety into
training programs Collaborating across disciplines Contribute to creating a culture of safety. As
patient advocates, health care professionals owe their patients nothing less.
Center for Patient Safety should…
4. Define feasible prototype systems (best practices) and tools for safety in key processes, including both clinical and managerial support systems for… management of diagnostic tests,
screening, and information…
Improve Access to Accurate, Timely
Information
Information about the patient, medications, and other therapies should be available at the point of patient care, whether they are routinely or rarely used. Examples of ways to make such information available are the following
Improve Access to Accurate, Timely
Information
• Have a pharmacist available on nursing units and on rounds.(why just a pharmacist? Commercial minute for the professional DLM doctorate…)
• Use computerized lab data that alert clinicians to abnormal lab values.
• Place lab reports and medication records at the patient's bedside.
• Place protocols in the patient's chart.
Improve Access to Accurate, Timely
Information
• Color-code wristbands to alert of allergies.
• Track errors and near misses and report them regularly.
• Accelerate laboratory turn around time.…also noted the importance of involving
the patient in their own care…commercial about the ASCLS consumer webpage
Joint Commission on Accreditation of Healthcare Organizations
Speak Up: Help Prevent Errors In Your Care Brochures and Poster
Speak Up Poster Hospitals (English)
Ambulatory Care Hospitals (Spanish)
Behavioral Health Care Laboratory Services
Health Care Networks Long Term Care
Home Care
http://www.jcaho.org/general+public/gp+speak+up/speak+up_bro.htm630-792-5800, option 5
So what’s happened since 1999?
2001 Congress: $50E6 for safety research IOM: The Quality Chasm
2004 Congress named Agency for Healthcare
Research and Quality Center for Quality Improvement and Safety
Education, training, dissemination, setting standards
Health and Human Services Agency for Healthcare Research and Quality Quality & Patient Safety Health Information Technology
Electronic health records — innovation — privacy — international standards — data sources — clinical vocabulary
National Quality Measures Clearinghouse™Evaluate health care quality — online database — process — outcome — access — patient experience
CAHPS®—Consumer Assessment of Health PlansConsumer feedback — survey and report tools — fact sheet — impact
Measuring Healthcare QualityStudies and projects — standardized methods — performance measures
Medical Errors & Patient SafetyScope of problem — reducing errors — research program — patient tips
WebM&M: Morbidity & Mortality RoundsPatient safety forum— learning modules — analysis of medical errors
Quality IndicatorsHospital quality measures — prevention — inpatient — patient safety
Quality Information & ImprovementEmployer experience — consumer information — case studies — glossary
TalkingQualityCommunicating with consumers — health care report cards
2005 JAMA (Lucian Leape, Donald Berwick)
Computerized prescribing
Including pharmacists on rounds
Standardizing medication practices
Errors 80%
Preventable adverse events down 78%
Adverse events down 60%
Am J Clin Pathol Volume 120, 18-26, 2003 Classifying laboratory incident reports to
identify problems that jeopardize patient safety
129 incidents 95% potential adverse events 73% preventable
71% preanalytical, 18% analytical, , 11% postanalytical
30% involved cognitive error (incorrect choices caused by insufficient knowledge)
73% involved noncognitive error (lapses in expected automatic behavior)
ADVANCE for MLP 11/7/05 Quashing errors Streamlining… the lab professionals getting
involved in the training of nurses… Cited Clin Chem 1997 paper (Plebani et al)
46% lab errors = preanalytical phase 68.2% of these = specimen collection Note…we usually haven’t a clue if it’s been drawn
correctly unless it’s in the wrong tube…
Comment on the Clin Chem paper
1998, Volume 44: 1066-67, Witte et al.
Analyzed 219,353 clin chem results and found 98 errors 447 ppm Anesthesia errors = 2.5 ppm Aviation errors = 0.18 ppm We have a ways to go!!
And then there are the blood glucose meters…
11/9/05 Glucose readings done using stix having
glucose dehydrogenase pyrroloquinolinequinone (GDH-PQQ) as the method
Falsely increases glucose levels in patients receiving parenteral products containing maltose, galactose, d-xylose
Peritoneal dialysis Immune globulin
Our turn!