iatrogenesis
Greek for originating from a physician
preventable adverse events
those that occurred due to error or failure to apply an accepted
... [Show More] strategy for prevention
Ameliorable adverse event
events that, while not preventable, could have been less harmful if care had been different
adverse events due to negligence
those that occurred due to care that falls below the standards expected of clinicians in the community
near miss
an unsafe situation that is indistinguishable from a preventable adverse event except for the outcome - exposed but does not experience harm either through luck or early detection
error
broader term referring to any act of commission or omission that exposes patients to a potentially hazardous situation
adverse event
An injury caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced at disability at the time of discharge, or both
commision
doing something wrong
omission
failing to do the right thing
CPOE
Computerized Provider Order Entry
2009 HITECH Act and meaningful use program
computer alerts three main findings
1. modestly effective at best
2. alert fatigue is common
3. fatigue increases with exposure and heavier use of CPOE systems
minimize alert fatigue
1. increase alert specificity to reduce inconsequential alerts
2. tier alerts according to severity
3. make only high level/severe alerts interruptive
4. use human factors principles
three concepts that influence safety in ambulatory care
1. role of pt and caregiver behaviors
2. role of provider-pt interactions
3. role of community and health system
Medical Office Survey on Pt Safety Culture
designed to assess safety culture in amb care and data is available from AHRQ
Pt Engagement
1. ed pt about their illness and medications with pt demonstrating understanding "teach back"
2. empowering to act as a safety double check
checklist
Algorithmic listing of actions to be performed for a given clinical procedure designed to ensure that no matter how often performed by a given clinician, no step will be forgotten
reduce risk of slips
consensus of required behaviors
slips
failure of schematic (autopilot) behaviors
lapses in concentration, distractions, or fatigue
mistake
failures in attentional behavior
lack of experience or insufficient training
Situational Awareness
the ability to access and track relevant to the task,
comprehend the data,
forecast what may happened based on the data, and
formulate an appropriate plan in response
situational awareness cannot be achieved without
clear and high-quality communication between all providers
most common root cause of sentinel events
communication
elements the affect communication
1. rigid hierarchies
2. overtly disruptive and unprofessional behavior
3. nonverbal cues
4. interpersonal relations
5. group dynamics
communication tools
read-back protocols
SBAR
teamwork training
process for prescribing and adm meds
1. order
2. Transcribing
3. dispensing
4. administration
90% errors occur at ordering (48%) or transcribing thus CPOE prevent
CDSS
Clinical Decision Support System
assist healthcare providers in the actual diagnosis and treatment of patients, analyze data from clinical information systems
avoids commission and omission errors
unintended consequences of CPOE
1. more or new work for clinicians
2. unfavorable workflow
3. never-ending system demands
4. persistence of paper orders
5. changes in communication patterns and practices
6. neg towards new technology
7. new types of errors
8. change in power structure, org culture , or professional roles
High Reliability Organizations (HROs)
persistent mindfulness with in an organization
cultivate resilience by relentlessly prioritizing safety over other performance pressures
consistently minimize adverse events despite carrying out intrinsically complex and hazardous work
safety is emergent vs. static
commitment to safety at all levels
HRO key features
1. know high-risk nature of activities and determine to have consistent safe operations
2. blame-free
3. collaboration across ranks and disciplines
4. commitment of resources to address safety concerns
Patient Safety Culture Surveys and Safety Attitudes Questionnaire
ask providers to rate the safety culture in their units and org as a whole
poor perceived safety culture= increased error rates
just culture
id and addressing systems issues that lead individual to engage in unsafe behaviors while maintain accountability
human error (slip)
at risk behavior (short cuts)
reckless behavior (ignoring required safety steps)
Debriefing
dialogue to learn from defects and improve performance through goal discussion, reflection to incorporate improvement or discover opportunities in future performance
simulation
real-life emergency responses
teamSTEPPS
Components of debriefing
1. setting the stage
2. description or reactions
3. analysis
4. application
plus delta debriefing
1. What went well?
2. What did not go well?
3. what can we do differently or what needs to change to improve care?
debriefing framework
team evaluates if:
had clear communication
understanding of roles & responsibilities
maintained sit awareness
distributed workload
cross-monitoring (asked and offered help prn)
made, mitigated, or corrected errors
detecting errors and safety hazards
goal to prospectively id hazards before pt harmed and analyzing events that have occurred to id and address underlying systems flaws
FMEA
Failure Mode and Effects Analysis
1. id all process steps "process mapping"
2. how each step can go wrong "failure modes"
3. impact of each error
4. likelihood of process failure
5. chance of detecting failure
6. impact of error
SWIFT
structured what-if technique
perceived safety problems can be detected through
safety culture surveys
executive walk rounds
techniques to retrospectively id safety hazards
1. screen larger datasets for evidence of preventable adverse events that merit further investigation (trigger tools, patient safety indicators)
2. analyze individual cases of adverse events (RCA, mortality reviews, in-depth investigation)
Patient Safety and Quality Improvement Act
Jan 2009
confidential and privilege protections for pt safety info when HCP work with Patient Safety Organizations
hazard detection methods
voluntary error reports
malpractice claims
pt complaints
executive walk rounds
risk mgmt. database
per Harvard Medical Practice Study, what % of errors were diagnostic
17%
9% were undetected while pt was alive
heuristics
Mental shortcuts or "rules of thumb" that often lead to a solution (but not always)
availability heuristic
dx of current pt biased by experience with past cases (crushing chest pain=MI)
anchoring heuristic
relying on initial dx impression despite subsequent info to the contrary (BC with corynebacterium txed as contaminant when endocarditis)
framing effects
dx decision making unduly biased by subtle cues and collateral information (addicted pt with abd pain tx for withdrawal but had bowel perf)
blind obedience
undue reliance on test results or expert opinion (false neg rapid Strept test)
prominent reason for malpractice claims
missed or delayed dx
predisposing factors for dx error in ES and surgery
poor teamwork
communication
gold standard for diagnosis
autopsy
goals is to have 25% inpt deaths autopsied
prevent dx errors
1. info technology
2.telephoen triage
3. teamwork & communication training
4. increased supervision of trainees
mega-cognition
cognitive psychology
reflect on own thinking with the hope to catch own misuse of heuristics before cause harm
components of disclosure that matter most to pts
1. disclosure of all harmful errors
2. explanation why occurred
3. how error's effects will be minimized
4. steps taken to proven recurrences
Full Disclosure Principle
disclose all circumstances and events, acknowledgement of responsibility, and apology
fewer malpractice lawsuits and lower litigation cost
CANDOR
Communication and Optimal Resolution
used with disclosure of events
% who reported witnessing physicians engage in disruptive behavior vs. nurses
77%
65% [Show Less]