Transcript Case Study Chemotherapy-related medication errors

Patient’s Safety:
Could It Truly Be This Awful?
Marwan GHOSN,MD, MBA/MHM
Objectives
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Sensitize the audience on the dimension of the
problem
Define the medication error and its impact on Patient
Safety and Healthcare System
Emphasize on the role of nurses on Patient Safety
Quality and Patient Safety
Hospital Accreditation
Six Key Aims of Health Care
Safety Comes First !
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Safe – avoid injuries to patients
Effective – based on science
Patient centered – respectful,
responsive
Timely – reduces wasteful delays
Efficient – avoid waits
Equitable – across gender, race,
location,
and ability to pay
Medication Errors
in numbers
22 July 2015
When Mistakes are not an Option
4
> 1,000,000
Serious Medication
Errors per year
in USA...
Ref: Wall Street Journal/Institute of Medicine
22 July 2015
When Mistakes are not an Option
5
195,000
hospital deaths
per year in the U.S.
as a result of
healthcare error
2000-2002
Source: Boston Globe – 27.July.2004
HealthGrades / Denver
44,000
preventable
deaths
occur each year
Source: Boston Globe – 27.July.2004
HealthGrades / Denver
“When I climb Mount
Rainier I face less risk
of death than I’ face
on the operating
table.”
Donald Berwick*, “Six Keys to Safer Hospitals: A Set of Simple Precautions Could Prevent
100,000 Needless Deaths Every Year,” Newsweek (12.12.2005)
*Donald Berwick is the President & CEO of the Institute of Healthcare Improvement (IHI)
Tommy Thompson, Secretary of the United
States Department of Health & human
"Some
grocery stores have better
technology than our
hospitals and clinics.”
Services (2001-2005):
Source: Special Report on technology in healthcare, U.S. News & World Report (07.04)
Do these numbers
give you a pause
when you will decide
to go to the hospital
?
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What is
“Medical Error”?
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Definition of a Medication Error
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Any preventable event that may cause or lead
to inappropriate medication use or patient
harm while the medication is in the control of
the health care professional, patient, or
consumer.
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Medication Error include
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Delayed diagnoses
Mistakes during treatment
Medication mistakes
Delayed reporting of results
Miscommunications during transfers and transitions
in care
Inadequate post-procedure care
Mistaken identity
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Medication Error include
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Error of commission:
 Act of doing something incorrectly
 Under normal circumstances that don’t include
stress & time pressures: 3 times out of 1000
Errors of omission:
 Something that should be done are not done
 In the absence of reminders: 1 time in 100
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Examples
Transdermal patches
•Appliance of the new patch directly on top
of the old one.
•Not removal of the protective linear
•Not removal of the old patch when the new
patch is applied.
•Difficult to find “clear” patches on the skin
•Accidental and intentional ingestion
Medication Error-prevention Strategies
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Educational and competency requirements for practitioners
Organized and up-to-date patient medical record and
medication profile
Coordinated care among practitioners.
Standardized medication ordering system:
 Preprinted medication order forms
 Computerized prescriber order entry system
 Standardized format for medical order content including:
dosage calculations, vocabulary and nomenclature,
abbreviations, dosage limits and routes of administration.
Medication Error-prevention
Strategies
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Standardized protocols for prescribing, preparation, dispensing,
and administration of medication:
 Medication-order verification system (9 checkpoint system)
 Documentation such as checklists, worksheets to calculate
dosages and administration rates, and treatment flow sheets
 Cross-checking
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Manual or electronic medication monitoring
Patient and caregiver education
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Medication Error-prevention
Strategies
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Quality assurance:
 Periodic auditing of
practitioner proficiency
 Error reporting system
 Analysis and resolution of
medication errors
 Periodic re-evaluation of
medication use system
What are the impacts of medical
error?
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Harm to the patient
Moral Imperative
Professional Imperative
Financial Imperative
Let’s have a look on some
concrete numbers ……
Medical errors
result in injury cost
$17 to $29 Billion
each year in USA
Ref: Kohn LT, Corrigan JM, Donaldson MS (eds). Committee on Quality of Health Care in America, Institute
of Medicine. To Err is Human: Building a Safer health System. Washington, DC: National Academies20
Press; 1999.
Nosocomial bloodstream infections
prolong a patient’s hospitalization
by a mean of
7 days =>
Cost per bloodstream infection
range
$ 3,700 and $ 29,000
Ref: Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and
mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted,
cohort study. Infection Control and Hospital Epidemiology. 1999; 20 (6): 396 – 401.
Preventable Adverse drug
events increase in length
stay of
4.6 days at a cost of $
4,685 each
Ref: Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S. Attributable morbidity and
mortality of catheter-related septicemia in critically ill patients: A matched, risk-adjusted,
cohort study. Infection Control and Hospital Epidemiology. 1999; 20 (6): 396 – 401.
Focusing On
Nursing !
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Nurse Staffing, Quality of Care & Outcomes
Educational levels of hospital nurses and
surgical patient mortality
JAMA 2003
Nurse Staffing and impact on clinical
outcome
Nurse care for
8 pts
Risk-adjusted mortality
rates following common
inpatient surgical
procedures
Failure to rescue rates
Nurse care for
4 pts
+ 31 %
would be expected
to prevent 5 deaths
per 1000 pts
Ref: Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and
job dissatisfaction. JAMA. 2002;288:1987-1993. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of
hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623. Aiken LH, Clarke SP, Sloane DM, for the
International Hospital Outcomes Research Consortium. Hospital staffing, organization, and quality of care: cross-national
findings. Int J for Qual Health Care. 2002;14:5-13 .
Education and work environment impact
on clinical outcome
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Every 10% increase in the proportion of a hospital’s
staff nurse workforce with a baccalaureate degree
or even higher levels of education is associated with
a 5% decline in mortality.
Hospitals with better nurse work environments have
fewer adverse patient outcomes than hospitals with
poorer work environments.
Turnover rate
Experience of Hackensack Hospital
in New Jersey
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Relates its low voluntary turnover rate of RN (6.3%) to the
excellent practice environment for nurses.
This translates into savings of $ 45,000 to $ 68,000 in
recruitment & training expenses for each nurse.
A low turnover rate is associated with a culture that
supports patient safety
The nursing practice environment is critical to patient safety,
quality of care & nurse retention.
Significant progresses have been made when
looking at local results under surveillance
Micro Results:
Significant
Progress
Leape & Berwick,
JAMA 2005
But much little progresses when
Macro Results:
Little Progress looking at macro results…
Global shift: safety improvement along time of all human
activities (order of magnitude : one log every 20 years) but the
relative ranking of activities does not seem to change
Cardiac Surgery
Patient ASA 3-5
Medical risk (total)
Hymalaya
mountaineering
Microlight or
helicopters
spreading activity
10-2
Very unsafe
10-3
Anesthesiology
ASA1
Chartered Flight
Railways (France)
Road Safety
Chemical Industry (total)
10-4
Civil Aviation
10-5
No system beyond
this point
Fatal Iatrogenic
adverse events
Nuclear Industry
Fatal
Ultra safe risk
10-6
Conclusion (1)
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The environments in which nurses work are complex systems
that are prone to error.
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Errors in nursing care are rarely due to carelessness or
incompetence.
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Consequently, the culture of health care organizations, created in
part by nurses, needs to be “blame free”.
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A learning environment, with free flowing open communication
enables nurses to identify, discuss and ultimately prevent health
care errors.
Conclusion (2)
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Patients deserve and have a right to care that
minimizes the likelihood of errors and that puts
their safety first.
To achieve that aim, nurses and other
stakeholders in health care have significant
work ahead.
Safety
Begins
with
you
Don’t
Wait for
someone
else