Transcript Document
Objectives
By the end of this session you will be able to: •explain the term ‘error’ •explain why errors are made •describe individual strategies to reduce the frequency of errors
Patient Safety and the Australian Curriculum Framework for Junior Doctors
Adverse events in health
• Contribute to about 18,000 deaths per year in Australia (approximately 10 times the road toll) • Occur in up to 16% of all hospital admissions Quality in Australian Healthcare Study (Wilson et al. MJA 1995)
Click to view video
Have you made any silly mistakes recently?
What happened?.......
What were the consequences?.....
What is an “error”?
“ Doing the wrong thing when meaning to do the right thing ” (Runciman) A more formal definition is: (Reason) “planned sequences of mental or physical activities that fail to achieve their intended outcomes, when these failures cannot be attributed to the intervention of some chance agency”
Error and outcome
• Error and outcome are not inextricably linked – Harm can befall a patient in the form of a complication of care without an error having occurred 1 – Many errors occur that have no consequence for the patient either due to a timely intervention (eg clinical pharmacist intercepting wrong dose) or due to chance (QAHCS – 75% of incidents had an element of ‘human error’)
Basic principles about error
1. We all make errors all the time 2. The same error (even minor ones) can have different consequences 3. Errors are not bad or morally wrong – BUT Healthcare workers expect perfection of themselves (and colleagues) AND We often ascribe blame to individual without looking at wider circumstances Adapted from Queensland Health Human Error and Patient Safety Training (HEAPS)
In hospitals the effects of small errors can be large!
Outcome Definitions
• Clinical incident • Near miss (or ‘no-harm incidents’) • Adverse event (or ‘harm incidents’) • Harm • Sentinel event • Clinical incidents = Near misses (90%) + Adverse events (10%)
Types of errors
Reason
Types of errors
• Slips - I put salt in my tea not sugar… • Lapses - I was interrupted and forgot to take the document out of the copier… – Usually repetitive actions • Mistakes - I thought the problem was hypovolaemia but it was cardiogenic shock… – Wrong plan or action
Courtesy P. Croskerry Courtesy P. Croskerry
Courtesy P. Croskerry
Courtesy P. Croskerry Courtesy P. Croskerry
Why do we misinterpret things sometimes?
Because the human brain is so…. • Good at finding shortcuts (fast) • Good at filtering information • Good at making sense of things • Usually this is a good thing, sometimes it fools us • Error is the “downside to having a brain”!
The environment can “set us up” to make errors
• look-alike and sound-alike pharmaceuticals • equipment design – e.g. defibrillators • user interfaces – e.g. infusion pumps
Situations leading to error: The “Three Bucket” model
Poor knowledge Fatigue Little experience Feeling ill Reason 2004 Distraction Inadequate handover Production pressure Equipment failure Variation from “normal” Omission errors Unfamiliar equipment
VIDEO
• Watch this video of a “typical day” in the emergency department • How did the mistakes come about?
• Were they inevitable or avoidable?
Click to view video.
Do not interrupt video once started.
Let video run through its entirety.
VIDEO
• What circumstances have you noticed so far that may contribute to an error?
• What strategies is the junior doctor using to minimise these factors?
Click to view video.
Do not interrupt video once started.
Let video run through its entirety.
What were the contributing factors in this case?
Poor knowledge Fatigue Little experience Feeling ill Reason 2004 Distraction Inadequate handover Production pressure Equipment failure Variation from “normal” Omission errors Unfamiliar equipment
Performance-shaping factors
• I Illness • M Medication – prescription, alcohol & others • S Stress • A Alcohol • F Fatigue • E Eating Am I safe to work today?
Stress and Performance
Area of “Optimum” Stress Low Stress Boredom High Stress Anxiety, Panic Stress Level The Relationship Between Stress and Performance
Stress and Performance
Don’t forget ….
H A L T If you’re – H – A ungry ngry – L ate or – T …..
ired
Personal error reduction strategies • Know yourself – eat well, sleep well, – look after yourself … • Know your environment • Know your task • Preparation & planning – “What if …?” • • Build ‘checks’ into your routine
Speak up if you don’t know!
Systems problems
• May be inadequate staffing, too busy etc.
• Design of equipment makes it difficult to do the right thing • Difficulties working as a team • No or patchy orientation • Often no clear accountability • No ‘standard operating procedures’ • Culture which allows unacceptable behaviours
Communication and Teamwork
• Be precise with your communication – Use clinical terms not social speak • Practice effective handovers • Encourage ‘read-back’ of important information – eg. Confirming instructions or drug doses if given over the telephone • Remember to have structured briefings (‘Time outs’) before procedures • Have a structure and plan what you need to say…
Education package available from PMCV and Southern Health
Mental preparedness
• Assume that errors can and will occur • Identify those circumstances most likely to lead to error • Have contingencies in place to cope with problems, interruptions and distractions – discuss them aloud with your team • Mentally rehearse complex procedures
Getting the balance right
Technology
• New technology doesn’t solve the problems • New technology makes new problems or can even make old problems even worse!
New technology makes new errors… Errors in counting drops per minute OR Mis-programming (eg. 10-fold or decimal point errors) Risk of unnoticed OR occlusion Risks of malfunction, battery failure, ignoring alarms etc.
Summary
• Making errors is an inevitable part of the human condition it’s how we’re built!
• Be aware of yourself, the context and the task – ask: – “what are the risks?” – “what are the ways to minimise the risk?” • Communicate effectively and use your team – they are your eyes and ears