Transcript Saeid Eslami

Saeid Eslami
[email protected]
Errors and ADEs are costly
Adverse Events in USA Hospitals:
 80,000 people hospitalised/year
 7,000 deaths/year.
 50% of these errors definitely or
possibly preventable
 $22 billion, costs of preventable
adverse events
(1999 USA Institute of Medicine Report)
Errors and ADEs are costly
At least 1.5 million preventable
ADEs occur each year in the
US:
 Hospital: 380,000-450,000.
 Ambulatory Care: 530,000
 Long-term care: 800,000
Cost of ADE
 Non-preventable ADE: $2,595
 Preventable ADE: $4,685
Bates DW et al . JAMA. 1997
‫ من موبایلمو‬،‫خبر خوب‬
!‫پیدا کردم‬
‫ رو ویبراتور‬،‫خبر بد‬
!!‫بوده‬
Errors and ADEs are costly
In Holland (2005):
 Each year 10,000 people receive wrong medication
and more than 3000 death each year because of errors.
In Australia:
 Medical error results in as many as 18 000
unnecessary deaths, and more than 50 000 patients
become disabled each year.
 AU$ 5 Billion (AUS)
Medication Errors
 nearly 1 of every 5 doses in the typical hospital and skilled
nursing facility.
 The percentage of errors rated potentially harmful was
7%, or more than 40 per day in a typical 300-patient
facility.
 The problem of defective medication administrations
systems, although varied, is widespread.
Medication Errors Observed in 35 Health Care Facilities Kenneth N. Barker, PhD; Elizabeth A.
Flynn, PhD, et al. (REPRINTED) ARCH INTERN MED/VOL 162, SEP 9, 2002 2002
American Medical Association
Adverse Events -International information
AE’s
Preventable
 Baker et al, Canada 2000
 7.5%
36%
 Thomas et al, Utah Colorado
 2.9%
--
 16.6%
51%
 10.6%
--
 3.7%
--
 10.8%
48%
 12.9%
37%





1992
Wilson et al,* Australia, 1995
Thomas et al, 2000, reworked
1995 Australian data
Brennan et al, Leape et al, New
York 1984
Vincent et al, London 1999,2000
Davis et al*, New Zealand 1998
* Slight to modest evidence of healthcare management causation = 2 out of 6
scale, other papers management causation more certain:- 4 out of 6 scale
Estimated Deaths Due to Medical Error
Source – The Philadelphia Inquirer
The National Burden of Systemic Errors in the
Health Care
(US)
More than 3 fully occupied
Jumbo jets of the Health
Care Industry drop out of the
sky every day !
(Adapted from Leape:
the Patient Safety Guru of USA)
In 2001 there were 4.3 million
ambulatory visits for treating
Adverse Drug Events Zhan et al 2005
And then there are other adverse Events!!
How Hazardous Is Health Care?
(Modified from Leape)
Dangerous
Ultra-Safe
Regulated
(<1/100K)
(>1/1000)
100000
HealthCare
Driving
Total lives lost per year
10000
1000
Scheduled
Airlines
100
Mountain
Climbing
Bungee
Jumping
10
1
1
10
100
1000
Chemical
Manufacturing
Chartered
Flights
10000
100000
Numbers of encounter for each fatality
European
Railroads
Nuclear
Power
1000000
10000000
Definitions:
………Patient safety defined as freedom from
accidental injury due to medical care…..
Institute of Medicine. To Err is Human. Building a safer Health System, Washington,
National Academy Press: 1999
An adverse events: harm or injury caused
by the management of a patients’ disease or
condition by health care professionals
rather than by the underlying disease or
condition itself……
The World Health Profession Alliance
Definitions:
 Sentinel Event
 An unexpected occurrence involving a death or serious




physical or psychological injury or risk thereof. Serious
injury specifically includes loss of limb or function.
Preventable Adverse Event
 Could/should not have happened (Error)
Non-Preventable Adverse Event
 Could not have been predicted or foreseen
Potential Adverse Event
 “Near miss” or “close call”, could have resulted in an
accident, injury or illness, but did not, either by chance or
through timely intervention
Error
 the failure of a planned action to be completed as intended
 the use of a wrong plan to achieve an aim.
11
Errors Types (another classification)
Overuse
in 2001 top 50 medical and surgical procedures
numbered 42 million. 7.5 million of these were
unnecessary surgical procedures – causing about
40,000 deaths.
Underuse
Much greater problem than Overuse. Patients failed to
receive recommended care about 46% of the time. e.g.
hypertension receives 65% of recommended care.
Misuse
About 11% of the time patients receive care not
recommended – leading to harm
G and R Singh
Medical Errors & Adverse Events
Non-preventable
Medical Errors
AE
Near
Miss
Preventable AE
Serious Medical Errors
13
Patient’s Encounter with
Health Care System
No error occurs
IF
ACTION
RQD
OUTCOME
IF
A, R & G Singh 2002
Unavoidable
adverse event
occurs
Advances in
medical knowledge
required to prevent
recurrence
Beneficial
outcome may
occur
Opportunities for
system redesign
and improvement
– commonly go
unnoticed
Patient’s Encounter with
Health Care System
IF
Error occurs
IF
Consequential
A, R & G Singh 2002
ACTION
RQD
System redesign
and improvement
required to
prevent
recurrence
OUTCOME
Preventable
adverse event
occurs
Patient’s Encounter with
Health Care System
IF
Error occurs
IF
ACTION
RQD
OUTCOME
Inconsequential on its own
A, R & G Singh 2002
Beneficial
outcome may
occur
Opportunities for
system redesign
and improvement
– commonly go
unnoticed
Patient’s Encounter with
Health Care System
Error occurs
IF
IF
Inconsequential on its own
IF
ACTION
RQD
OUTCOME
Undetected
(may cause
cascade of
errors)
A, R & G Singh 2002
IF
Preventable
adverse event
occurs
System redesign
and improvement
required to
prevent
recurrence
Patient’s Encounter with
Health Care System
No error occurs
Error occurs
IF
IF
Inconsequential on its own
Consequential
IF
Detected and
corrected
ACTION
RQD
Advances in
medical knowledge
required to prevent
recurrence
Beneficial
outcome may
occur
Opportunities for
system redesign
and improvement
– commonly go
unnoticed
Preventable
adverse event
occurs
System redesign
and improvement
required to
prevent
recurrence
ACTION
RQD
A, R & G Singh 2002
Unavoidable
adverse event
occurs
IF
OUTCOME
OUTCOME
IF
Undetected
(may cause
cascade of
errors)
Isordil
or
Plendil?
Other Example:
-Glucose
-Oxygen/CO2
What shall manager do?
How can we prevent them?
More Common than We Thought
• Underestimated by a factor of 20 or
greater
• Reports in health care would presumably
number in the millions if adverse events,
no harm events, and near misses were
captured.
Agency for Healthcare Research and Quality, Making Health Care Safer: A Critical
Analysis of Patient Safety, July 2001 Donald Holmquest, MD, PhD, JD
Chief Technology Offices, eMedical Research, Inc. – 3000 medical fatal errors for
1,000,000 people
Richard Smith
“Knowing is not enough;
we must apply. Willing is
not enough; we must
do.”
Wolfgang von Goethe
How to think of error?
 An individual failing
 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)
 A systems failure
 This is the starting point for redesigning the system and
reducing error
James Reason’s bottom line
Fallibility is part of the human
condition
We can’t change the human
condition
We can change the conditions
under which people work
Good Outcomes, Good Systems
• Historically, mistakes or poor outcomes have been blamed
on “dumb doctor,” or “dumb nurse.” The “solution” was the
ABP reaction – Accuse, Blame and Punish.
• But inefficiencies and errors mostly can be traced not to one
error, but a cascade of poor or poorly executed procedures,
policies, technologies and training. A good system will
provide a good outcome; a poorly designed one will produce a
poor one.
•We need to design health care systems that put safety first
(First, do no harm)
Hopkins Medical News, Edward D. Miller, M.D., Fall 2002, Page 56
A System Problem
“…adverse events are generally not the
result of one thing that went wrong. They
result from the combination of a series of
latent errors that are built into the system.”
Paul M. Schyve, MD, Vice President, JCAHO In: Reducing Medical Errors,
Improving Patient Safety: Taking the Next Step, HealthLeaders Roundtable,
June 2001.
‘Swiss cheese’ model
SAFETY BARRIERS
Be careful!
Theory of Constraints
 Any improvement is a change
 not every change is an improvement
 but we cannot improve something unless we
change it
Goldratt (1990)
Any improvement is a change
 any change is a perceived threat to security
 there will always be someone who will look at the
suggested change as a threat
 any threat to security gives rise to emotional
resistance
 you can rarely overcome emotional resistance with
logic alone
 emotional resistance can only be overcome by a
stronger emotion
Goldratt (1990)
“Anyone who thinks you
can overcome
emotional resistance
with logic was probably
never married”
Panic
Zone
Comfort Zone
•people stay here
•they don’t learn
•they don’t change
•people
close up
•they
freeze
•they don’t
learn
Panic
Zone
Comfort Zone
Discomfort
Zone
•uncertainty
•learning
It is important to be aware of:
“Tell me and I will forget
Show me and I may remember
Involve me and I will understand”
Emotionally, Intellectually
and physically
BUT
Excluding the EGO
i.e. HALO!
In comparison with:
“See one
Do one
Teach one”
Involve the nurses
19-5-2016
39
Discipline of Improvement
4 equally important parts of
improvement
Involving users,
carers, staff and
the public
Personal and
organisational
development
Process and
systems thinking
Making it a habit:
initiating, sustaining
and spreading
improvement in
daily work
Vision: Every single person is capable, enabled and encouraged to work with
others to improve their part of the service
Discipline of improvement
in health and social care (Penny 2003)
Hospital standardised mortality rates by reference costs
140
130
120
HSMR 2002
110
100
90
80
70
60
50
50
60
70
80
90
100
110
Reference costs 2002
Source: ‘Pursuing Perfection’ programme
120
130
-Glucose
-Oxygen/CO2
What shall manager do?
How can we prevent them?
Safety Principles
 Error prevention
 Making errors visible
 Mitigation of harm from errors
 “No problem can be solved within the same
consciousness which caused it.”
Albert Einstein
 “Since modern information tools can do things that
the unaided human mind cannot do, when we use such
tools we may see a picture of medicine we have not
seen before.”
Larry Weed
 “…there are enormous ‘voltage drops’ along the
transmission line for medical knowledge.”
Lawrence Weed (1997)
Safety in Flying
 1903
 1908
 1910
 1918
 1994
First Powered Flight
First Pilot dies
First mid-air collision
31 of first 40 US Air Mail pilots
die in crashes
4 crashes/10,000,000 takeoffs
45
Flight vs. Healthcare
 Machine vs. Human (Flight)
 Human vs. Human (Healthcare)
Information Technology
“A growing body of evidence supports the
conclusion that various types of IT
applications lead to improvements in
safety… Nonetheless, IT has barely touched
patient care.”
Source: IOM, Crossing The Quality Chasm, p. 187.
Information Technology to Improve Patient
Safety
 Electronic medical records (EMR)
 Electronic orders and prescribing:
Computerized Physician Order Entry (CPOE)
 Electronic decision-support tools
 Handheld devices (PDAs)
 The electronic office
Technology has Become a Preferred Solution by
Many Groups:
 IOM reports
 Leapfrog
 ISMP
 Media
 Legislators
50
?
?
Order
____________________________________
Point of Care
N a triu m
K a liu m
C a lc iu m
M a g n e s iu m
A S AT
A L AT
a lk P a s e
gam m aG T
3
Dose calculation
• single dose
• dosing intervall
• divisibility
1
Watchdog
CPOE
Point of Care
2
• renal failure?
• special dose requirements?
• Contraindications?
Drug data base
• local formulary
• common thesaurus
Generation I
• Create a clinical data repository
consolidation key clinical data
• From this database, information can be
located efficiently and reliably
Generation I = 15% reduction in
preventable errors
Generation II
• Implementation of basic clinical decision
support systems (CDSS) - a key for
eliminating errors
GI (15%) + GII (25%) = 40% reduction in
preventable errors
Reducing Haphazard Decisions
What’s the last
Potassium ?
What does this
child weigh ?
What’s the dose
of potassium ?
Is there a
policy ?
Where are the
chart & blue card ?
How fast can I
give this drug ?
Protection from
Overdose?
… for example sedation
Midazolam (Dormicum®)
• sedative before interventions
(e.g. dental or other surgery, endoscopy)
• sedation in respirator therapy
• emergency treatment of epileptic fits
(e.g. status epilepticus)
Midazolam clearance
L/h/kg
0.7
0.6
0.5
0.4
0.3
0.2
Children
0.1
0
Born
4
8
Year
12
16
20
Clin Pharmacokinet 98;35:37
Adults
Midazolam distribution
L/kg
2
1.75
Children
1.5
1.25
1
0.5
0.25
0
Born
4
8
Year
12
16
20
Clin Pharmacokinet 98;35:37
Adults
0.75
Midazolam dosing according to weight
6
5
Children
4
Overdosing
3
2
Underdosing
Adults
1
0
Born
4
8
Year
12
16
20
Renal failure: risk without dose adjustment
Irreversible cerebellar
damage
Lithium
Aciclovir,
Cefuroxime
* 10
Concentration in renal
failure
Coma, epileptic fits
*8
Confusion
*6
Ranitidine
*4
*2
Baseline
* 0.5
Digoxin,
Imipenem
Grandmal
Bisoprolol
AV-Block
Metoprolol
Normal
75
50
25
Renal function
Arrhythmia, K+
Dialysis
5 drugs
}
Drug-Drug Interaction
10 combinations
10 drugs
45 combinations
Generation III
• Combining CDSS across the continuum of care (in and out
patients)
• Use of controlled medical vocabulary to normalize medical
concepts
• CPOE (to better manage ordering)
• Work flow improvements
• Combining work flow change and CDSS
• This 3rd generation has the basic infrastructure to measure or
asses incidence of potential errors and measure effectiveness of
interventions
GI (15%) + GII (25%) + GIII (30%) = 70% preventable error.
IOM goal of at least a 50% reduction of preventable medical
errors
Errors resulting in ADEs: Harvard Study
6% 4%
CPOE
eMAR &
Bar-coding
34%
56%
Bates DW et al. Incidence of adverse drug events and potential adverse
drug events. JAMA 1995;274:29-34.
64
Ordering
Administration
Transcription
Dispensing
‫خوب! راحت باش و روی‬
‫بارکدخوان دراز بکش!‬
Generation IV
• More sophisticated CDSS
• Tailored care to the individual patient
• Disease management tracking
• Protocols (Care management, Clinical)
•
GI (15%) + GII (25%) + GIII (30%) + GIV (20%) = 90%
preventable error.
Generation IV
After the next decade 2010
•Highly sophisticated CDSS
•True evidence-based medicine
•Outcomes tracking of each episode of care
•Links to NLM and new medical research results from
the medical literature
•Interfaces to mobile personal monitoring devices
•Personalized accessible patient record information
anywhere
PEDIATRICS Vol. 116 No. 5 November 2005
The Introduction of Computerized Physician Order Entry and Change
Management in a Tertiary Pediatric Hospital
Jeffrey S. Upperman MD; Patricia Staley BA; Kerri Friend BA; Jocelyn Benes RN; Jacque Dailey RN
William Neches MD; and Eugene S. Wiener MD
From the Departments of Surgery, Quality and Care Management, and
Cardiology, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Conclusion. CPOE is an invaluable resource for supporting patient safety in health care settings.
PEDIATRICS Vol. 116 No. 6 December 2005
Unexpected Increased Mortality After Implementation of a Commercially
Sold Computerized Physician Order Entry System
Yong Y. Han, MD; Joseph A. Carcillo, MD; Shekhar T. Venkataraman, MD; Robert S.B. Clark, MD;
R. Scott Watson, MD, MPH; Trung C. Nguyen, MD; Hülya Bayir, MD; and Richard A. Orr, MD
From the Departments of Critical Care Medicine and Pediatrics and
Clinical Research, Investigation and Systems Modeling in Acute Illness
(CRISMA) Laboratory, University of Pittsburgh School of Medicine,
Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
Conclusion. We have observed an unexpected increase in mortality coincident with CPOE implementation.
‫وووه! االن تصادف می‬
‫کنم ‪! ...‬‬
Technology Adoption, Change!
No. of years for 30% of Americans to own
technology:
• Telephone 40 years
• Television 17 years
• PC 13 years
• Internet 7 years
D.Z. Sand, HIMSS presentation 2002, Cambridge Technology Partners
Thermometers
“Physicians had always avoided
applying mathematics to the study of the
body or disease. In the 1820’s, 200 years
after the discovery of thermometers,
French clinicians began using them.”
The Great Influenza, John M . Barry p25
Main Barriers
• Physicians were taught to be independent and have
been resistant to guidelines and systems
• Physicians view teamwork as golf teams not
volleyball teams
• Disruptive behavior has been tolerated and in some
respects rewarded among physicians
‫مطالعه در حوزه امنیت پزشکی همانند الیه الیه کردن پیاز است‪،‬‬
‫هرچه بیشتر ادامه می دهید بیشتر پیدا می کنید‪،‬‬
‫و بیشتر گریه می کنید!‬
‫‪Point of Care‬‬