Transcript No Slide Title

An Excellent Health
Care Experience
A Commitment
to Patient Safety
Patient Safety
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What is it?
Why is it important?
What are we doing?
What is my part to play?
Patient Safety: What Is It?
Error -- Failure of a planned action to:
• be completed as intended or
• use of a wrong plan to achieve an aim
Patient Safety: What Is It
• Unsafe care can result from:
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Fragmented health care system
Faulty systems
Increasing complexity
Lack of awareness of extent of the problem
Culture of individual focus and blame
Lack of systemic view
Patient Safety: Why Is It
Important?
• Institute of Medicine report sites studies:
– Medical errors occur in 2.9% to 3.7% of
hospital admissions.
– 8.8% to 13.6% of errors lead to death.
– Between 44,000 and 98,000 deaths occur each
year in hospitals as a result of medical errors.
Deaths Due to Preventable
Adverse Events in Hospitals
• Using lower number (44,000), 8th leading
cause of death in the United States
• Exceeding
– Motor vehicle accidents (43,458)
– Breast Cancer (42,297)
– AIDS (16,516)
Institute of Medicine
report
Cost of Medical Errors
• 459 adverse events identified from 14,732
randomly selected discharges at an
estimated health care cost of $348 million.
(Not including cost of loss income, disability, etc.)
• 265 of the 459 adverse events found to be
preventable, which represents $159 million
in health care cost.
Institute of Medicine
report
Cost of Medication Errors
• Most do not result in harm but those that do
are costly.
• Recent study: 2% of admissions have a
preventable adverse drug event resulting in:
– increased LOS of 4.6 days
– increased hospital cost of $4,700 / admission
– totals $2.8 million for 700-bed teaching
hospital.
Institute of Medicine
report
Medications Administered in Allina
• More than 7 million doses of medications
are administered per year in Allina
Hospitals and Clinics.
• Is there an acceptable medication error rate?
– A 1% error rate would allow 70,000 errors.
– A 0.5% error rate would allow 35,000 errors.
– A 0.1% error rate would all 7,000 errors.
• Our goal is a fail-safe system that is free of
errors
This Doesn’t Happen Here.
Does it?
This Doesn’t Happen Here.
Does it?
Patient Safety: What Are We
Doing?
Allina Hospitals and Clinics
Patient Safety Vision:
Achieve patient care environments
free of accidental injury.
Safe Delivery Principles
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Standard processes for doses, dose timing and dose scales
Standardized prescription writing
Limit number of different kinds of common equipment
Implement physician order entry
Implement decision support (eg drug dose; drug-allergy)
Unit dosing
High risk IV supplied only by central pharmacy
Written protocols for high risk medications
No KCl on care units
Pharmacist on rounds
Patient information available at point of patient care
Allergy wristbands
Computer generated MARs
Bar coding
Swiss Cheese Model
Defenses Against Errors
Hazards
Ideal
Reality
Errors
J. Reason
Action: Create a Safety
Culture
That . . .
• understands systems and how errors
happen
• incorporates human factors research
• expects learning, not blame
• designs safe systems
Action: Allina Patient Medication
Safety Task Force
Goals:
– Increase awareness of unsafe systems.
– Implement mechanisms to allow learning from
errors.
– Establish the principles of safe systems.
– Initiate and complete rapid cycle improvements
in our systems.
– Improve reporting including near misses.
Patient Safety What Is My Part to Play?
• Practice Principles of Patient Safety
• Report
• Identify unsafe systems and take action
to protect the patient