10/28/2011

1

Reducing medical error and

increasing patient safety

Richard Smith

Editor, BMJ

What I want to talk about

A story

How common is error?

Why does error happen?

How should we think of error?

How should we respond?

10/28/2011

2

A story

How common is error?

Harvard Medical Practice Study

Reviewed medical charts of 30 121 patients

admitted to 51 acute care hospitals in New

York state in 1984

In 3.7% an adverse event led to prolonged

admission or produced disability at the time

of discharge

69% of injuries were caused by errors

10/28/2011

3

How common is medical error?

Australian study

Investigators reviewed the medical records of

14 179 admissions to 28 hospitals in New

South Wales and South Australia in 1995.

An adverse event occurred in 16.6% of

admissions, resulting in permanent disability in

13.7% of patients and death in 4.9%

51% of adverse events were considered to have

been preventable.

How common is medical error?

The differences between the US and

Australian results may reflect different

methods or different rates

Other, smaller studies (including one from

Britain) show similar orders of errors

There are few studies from outpatients or

primary care

10/28/2011

4

How common is medical error?

An evaluation of complications associated

with medications among patients at 11

primary care sites in Boston.

Of 2258 patients who had had drugs

prescribed, 18% reported having had a drug

related complication, such as

gastrointestinal symptoms, sleep

disturbance, or fatigue in the previous year.

Results of medical error

In Australia medical error results in as many

as 18 000 unnecessary deaths, and more

than 50 000 patients become disabled each

year.

In the United States medical error results in

at least 44 000 (and perhaps as many as 98

000) unnecessary deaths each year and 1

000 000 excess injuries.

10/28/2011

5

Types of error

About half of the adverse events occurring

among inpatients resulted from surgery.

Next come

Complications from drug treatment

therapeutic mishaps

diagnostic errors were the most common non-

operative events. In the Australian study

cognitive errors, such as making an

Types of error

Cognitive errors--such as incorrect

diagnosis or choosing the wrong

medication-- more likely to have been

preventable and more likely to result in

permanent disability than technical errors.

10/28/2011

6

Which patients are most at risk?

Those undergoing cardiothoracic surgery,

vascular surgery, or neurosurgery

Those with complex conditions

Those in the emergency room

Those looked after by inexperienced doctors

Older patients

10/28/2011

7

How dangerous is health care?

Less than one death per 100 000 encounters

Nuclear power

European railroads

Scheduled airlines

One death in less than 100 000 but more than 1000 encounters

Driving

Chemical manufacturing

More than one death per 1000 encounters

Bungee jumping

Mountain climbing

Health care

Why do errors happen?

All humans make errors: indeed, the ability

to make mistakes allows human beings to

function

Most of medicine is complex and uncertain

Most errors result from the system--

inadequate training, long hours, ampoules

that look the same, lack of checks, etc

Healthcare has not tried to make itself safe

10/28/2011

8

How to think of error?

An individual failing

Only the minority of cases amount from negligence

or misconduct; so its the wrong diagnosis

It will not solve the problem--it will probably in

fact make it worse because it fails to address the

problem

Doctors will hide errors

May destroy many doctors inadvertently (the

second victim)

10/28/2011

9

How to think of error?

A systems failure

This is the starting point for redesigning the

system and reducing error

How to respond? Tactics

Reduce complexity

Optimise information processing

checklists, reminders, protocols

Automate wisely

Use constraints

for instance, with needle connections

Mitigate the unwanted side effects of change

with training, for example.

10/28/2011

10

Building a safe healthcare

system (from James Reason)

Principles

Policies

Procedures

Practices

Building a safe healthcare

system (from James Reason)

Principles

Safety is everybodys business

Top management accepts setbacks and

anticipates errors

safety issues are considered regularly at the

highest level

Past events are reviewed and changes

implemented

10/28/2011

11

Building a safe healthcare

system (from James Reason)

Principles

After a mishap management concentrates on

fixing the system not blaming the individual

Understand that effective risk management

depends on the collection, analysis, and

dissemination of data

Top management is proactive in improving

safety--seeks out error traps, eliminates error

producing factors, brainstorms new scenarios of

failure

Building a safe healthcare

system (from James Reason)

Policies

Safety related information has direct access to

the top

Risk management is not an oubliette

Meetings on safety are attended by staff from

many levels and departments

Messengers are rewarded not shot

Top managers create a reporting culture and a

just culture

10/28/2011

12

Building a safe healthcare

system (from James Reason)

Policies

Reporting includes qualified indemnity,

confidentiality, separation of data collection

from disciplinary procedures

Disciplinary systems agree the difference

between acceptable and unacceptable behaviour

and involve peers

Building a safe healthcare

system (from James Reason)

Procedures

-Training in the recognition and recovery of

errors

Feedback on recurrent error patterns

An awareness that procedures cannot cover all

circumstances; on the spot training

Protocols written with those doing the job

Procedures must be intelligible, workable,

available

10/28/2011

13

Building a safe healthcare

system (from James Reason)

Procedures

Clinical supervisors train their charges in the

mental as well as the technical skills necessary

for safe and effective performance

Building a safe healthcare

system (from James Reason)

Practices

Rapid, useful, and intelligible feedback on

lessons learnt and actions needed

Bottom up information listened to and acted on

And when mishaps occur

Acknowledge responsibility

Apologise

Convince patients and victims that lessons learned

will reduce chance of recurrence

10/28/2011

14

James Reasons bottom line

Fallibility is part of the human

condition

We cant change the human

condition

We can change the conditions

under which people work

Conclusions

Human beings will always make errors

Errors are common in medicine, killing tens

of thousands

We begin to know something about the

epidemiology of error, but we need to know

much more

Naming, blaming and shaming have no

remedial value

10/28/2011

15

Conclusions

We need to design health care systems that

put safety first (First, do no harm)

We know a lot about how to do that

Its a long, never ending job