Understanding Adverse Events & Error Prevention in Patient Safety, Exams of Health sciences

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preventable adverse events - those that occurred due to error or failure to apply an accepted 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

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

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 that 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

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 - 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 situational 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. identify 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 identify 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)

hazard detection methods - voluntary error reports

malpractice claims

pt complaints

executive walk rounds

risk mgmt. database

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

prevent dx errors - 1. info technology

2.telephone triage

3. teamwork & communication training
4. increased supervision of trainees

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

physician disruptive and disrespectful behavior impact on nursing - dissatisfaction and likelihood of leaving nursing profession

adverse events in OR

disruptive behavior - disrespect for others

interpersonal interaction that impedes the delivery of pt care

subverts the org ability to develop a culture of safety (impacts teamwork and blame-free environment)

unprofessional behavior in medical school is linked to subsequent disciplinary action by licensing board

founder of patient safety movement - Dr. Lucian Leape

prevent disruptive behavior - code of conduct defines and managing behaviors

leadership in ensuring culture of safety

prevent behavior

problems with EHR - 1.poor info display

2. complicated screen sequences and navigation
3. mismatch between user workflow

safety hazards with data entry errors can be created by - 1. use of copy-forward or copy and paste

2. electronic signatures
3. lack of clarity in sources and date of information presented
4. alert fatigue
5. usability problems
6. altered workflow
7. altered communication

Med errors not impacted by EHR - 1. wrong pt (bar coding decreases error)

2. wrong med at time of selection
3. wrong time

SAFER guides - assessment checklists and structure for team to assess and improve their systems

1. high-priority practices
2. org responsibilities
3. contingency planning

4. system configuration
5. system interfaces
6. pt identification

7 CPOE with decision support

8. test result reporting and f/u
9. clinician communication

suitability safety risk for EHR - 1. lack support of workflow

2. lack data coding, std, and structure
3. lack duplicate record detection
4. inaccurate, incomplete, or outdated decision support rules
5. bugs in software
6. content import features

usability safety risk for EHR - 1. default values

2. problematic alerts
3. simultaneous task performance
4. inadequate info displays
5. unclear current state of user actio9ns in order processing
6. difficult interfaces
7. error-prone intervaces

Human Factors Engineering - interaction between workers, the equipment, and their environment

takes into account human strengths and limitations in the design of interactive systems

Human Factors Engineering - 1. physical demand

2. skill demands
3. mental workload
4. team dynamics
5. aspects of work environment
6. device design

goal is to compete the task optimally

usability testing - test in real-world conditions in order to id potential problems and unintended consequences of new technology

will id workarounds

forcing functions - prevents unintended or undesirable action from being performed or allows it performance only if another specific action is performed first (shift into reverse unless brake is pushed)

does not always involve device design (removing potassium from med rooms)

standardization - standardizing equipment and processes whenever possible to increase reliability, improve info flow, and minimize cross-training needs (checklists)

resiliency efforts - attention to detection and mitigation before events occur

dynamic aspects of risk mgmt. to anticipate and adapt to changing conditions and recover from system anomalies

High Reliability Organizations (HROs) - 1. preoccupation with failure

2. reluctance to simplify explanations for operations, successes, and failures
3. sensitivity to operations (situational awareness)
4. deference to frontline expertise
5. commitment to resilience

Health literacy - individual's ability to find, process, and comprehend the basic health info necessary to act on medical instructions and make decisions about one's health

universal precautions for health literacy - 1. create shame-free environment

2. simplifying info (3 to 5 pts, 4-6th grade level)
3. listen carefully
4. confirm comprehension (teach back or show me)
5. improving support for navigation healthcare contexts (signage, forms, apps)
6. support in health mgmt efforts

CUSP - comprehensive unit-based safety program

combines culture of safety, teamwork, and communications together with checklists that incorporate evidence-based measure to prevent HAI

fatigue - latent hazard and unsafe condition which leads to increased medical errors

cognitive performance less sensitive to sleep deprivation - complex tasks that are rule based & interesting

require critical reasoning in logical well-practiced tasks

mitigate the impact of extended work hours - conducting a risk assessment

robust handoff practices

involving staff design of work schedules

fatigue mgmt plan with strategic use of caffeine and planned naps

educate about sleep hygiene

adequate environment for sleep breaks

falls occur in elderly with - 1. delirium

2. psychoactive meds (benzodiazepines)
3. baseline difficulties with strength, mobility, or balance

Considerations in fall prevention program - 1. individualized

2. combine environmental measures (nonslip floors, within line sight)
3. clinical interventions (minimize deliriogenic meds)
4. care process interventions (std risk assessment tool)
5. cultural interventions (multidisciplinary)
6. tech/logistical interventions (lower bed)

2011 components of fall prevention interventions - 1. multidisciplinary

2. staff and pt ed
3. individualized POC
4. safe footware
5. focus on prevent, detect, and tx delirium
6. culprit meds
7. continence mgmt
8. device, mobility aids, and exercise
9. post fall review

falls reportable to TJC - falls with injury are serious reportable event and a "never event" by CMS

failure to rescue - not able to rapidly id and tx complications when they occur

inability to prevent death after the development of a complication

reflect resources and preparedness of system

how can a hospital have a low complication rate but high failure to rescue rate or vise versa - higher complications have more experience recognizing and responding to complications

The single greatest impediment to error prevention in the medical industry - we punish people for making mistakes

safe, high-quality care - well designed systems of care that are supported by individuals with a full range of competencies

improve performance - simulation

individualized coaching

CME

mandate to report suspected impaired or unable to perform pt care duties

leadership roles - 1. prioritizing safety

2. est culture of safety
3. responding to pt or staff concerns
4. supporting efforts to improve safety
5. monitor progress

Board of Directors Responsibilities - 1. formatting mission & key goals

2. ensuring financial viability
3. monitoring and eval performance of high-level executives
4. meets the needs of the community it serves
5. ensuring quality and safety of care

discontinuity creates - opportunities for error when clinical information in not accurately transferred between providers "kids playing telephone"

"handoffs" - transferring responsibility for a patient from one caregiver to another with the goal of providing timely, accurate information about a patient's plan of care, treatment, current condition and anticipated changes

leading cause of preventable error in ED physicians and trainees - communication failures

TJC handoff process - 1. interactive communications

2. up to date and accurate info
3. limited interruptions
4. process for verification
5. opportunity to review any relevant hx data

1999 institute of Medicine Report - "To err is human: building a safer health system "

toll of medical errors at the national level - 98,000 deaths every year due to preventable harm

no single validated method for measuring eh overall safety of care

measurement is sued to - 1. eval effectiveness of intervention

2. id new or emerging safety threats
3. compare safety across setting
4. determine if safety is improving

methods of measuring pt safety - 1. retrospective chart review - gold std

2. voluntary error reporting

3. automated surveillance
4. adm or claims data (AHRQ pt safety indicators)
5. pt reports

2015 Free From Harm by the National Patient Safety Foundation - call for creation of common set of safety metrics that reflect meaningful outcomes

1. est std set of process and outcome measures for use on a national basis
2. creating measures of pt safety for settings outside the hospital
3. improve the quality of safety reporting systems
4. develop ways of measuring safety in real time

most common medication errors - 1. wrong time of administration

2. omission
3. wrong dose
4. wrong prep
5. wrong adm rate (IV meds)

most common self and caregiver medication errors - 1. low health literacy

2. poor provider-pt communication
3. absence of health literacy universal precautions

prevention of medication errors - 1. barcoding

2. smart infusion pumps
3. single-use med packages
4. package design features
5. minimizing interruptions

medication error - an error of commission or omission at any step between prescribing and receiving the med

adverse drug event - harm experienced by a pt as a result of exposure to a medication

does not necessarily indicate an error or poor quality care

Preventable ADE - med error that reaches pt and causes any degree of harm

about half are preventable

potential ADE - med errors that do not cause any harm either because they are intercepted or luck

(incorrect dose given but no clinical consequences)

nonpreventable ADE - side effects

event when prescribed and adm properly

strongest risk factor for ADE - polypharmacy

STOPP criteria - Screening Tool of Older Persons' potentially inappropriate Prescriptions

more accurate predict ADE than Beers criteria

most commonly meds that cause ADE - 1. antidiabetic agents

2. oral anticoagulants
3. antiplatelet agents
4. opioid pain meds

medication reconciliation - screen for:

1. omitted needed meds
2. unnecessarily duplicate therapies
3. incorrect doses
4. incomplete list of all medications

Med rec is done - 1. time of admt

2. time of transfer
3. time of discharge

med rec alone does not - reduce readmissions or other ADE

• resource intensive
• disincentive from investing
• altered workflow
• inefficiencies and confusion
• conflict between med rec and other quality improvement priorities

nursing omission error - missed nursing care

needed nursing care that is delayed, partially completed, or not completed at all

structural factors contributing to missed nursing care - 1. labor resources

2. material resources
3. teamwork and communication

nursing decision process is influenced by - 1. nurse's perceptions of team or group norms

2. judgment about the importance of various aspects of care relative to the conditions of multiple pts
3. nurse's values, attitudes, and beliefs
4. nurse's usual practice

never events - Serious but preventable errors that should never occur

• unambiguous (id and measurable)
• serious (death or disability)
• preventable

Sentinel Event - an unexpected occurrence involving death, serious physical or psychological injury, or the risk thereof

categories of serious reportable events - 1. surgical or procedural

2. product or device
3. pt protected events
4. care mgmt events
5. environmental events
6. radiologic events
7. criminal

preventable adverse event - those due to error or failure to apply an acceptable strategy for prevention

patient-centered care - respectful of and responsive to individual pt preferences, needs, and values and ensure that pt values guide all clinical decisions

Engagement of patients in safety - 1. enlisting pt in detecting adverse events

2. empowering pt to ensure safe care
3. emphasizing pt involvmetn as means of improving the culture of safety

patient action errors - 1. pt behaviors

2. mental errors

errors related to radiotherapy - 1. overexposure

2. wrong pt
3. wrong site
4. poor communication
5. wrong dosing or incorrect configuration of equipment
6. inadequate training
7. poor interoperability of systems

diagnostic imaging prevention to limit radiation - 1. ed physicans on appropriate test utilization

2. std equipment
3. radiation dosage
4. use ultrasound or MRI instead

Rapid Response Team - a team that is trained to intervene and assist caregivers before a patient's condition deteriorates to the point that a conventional code is required.

ameliorated - to make better or more tolerable

prevention of adverse events after d/c - 1. med reconciliation

2. structured d/c communication

3. pt education

passive form of surveillance for safety - voluntary reporting for near misses or unsafe conditions

active form of surveillance for safety - direct observation

chart review using triggers

effective event reporting system - 1. supportive env for reporting that protects privacy who report occurrences

2. reports from board range of personnel
3. timely summaries disseminated
4. mechanism to review and dev action plans

two most commonly reported events - 1. medication errors

2. falls

top perceived barriers to incident reporting for Dr. - 1. no feedback or incident f/u

2. form to long or lack of time
3. incident was trivial
4. ward was busy or forgot to report
5. unsure of who should complete

active errors - occurring at the point of interface between humans and complex system

latent errors - hidden problems within health care systems that contribute to adverse events

factors that may lead to latent errors - 1. institutional or regulatory

2. organizational or mgmt
3. work env
4. team env
5. staffing
6. task related
7. pt characteristics

why RCA fail to result in improvment - 1. overreliance on weak solutions (education)

2. failure to aggregate data across institutions,
3. failure to incorporate principles of human factors engineering and safety science

levels at which damage from errors and adverse events occur - 1. the pt

2. clinicians
3. HC organizations

degree of distress - severity of error

degree of perceived responsibility

outcome of the pt

second victim - A healthcare worker who is traumatized by, or unduly punished for an error or adverse patient event is deemed to be a "second victim."

"Second victimization" was extremely common in the traditional "blameful" culture of American medicine that prevailed until the early part of the current century, where all errors and adverse events were blamed on one individual wherever possible.

Albert Wu 2000

stages of recovery for 2nd victims - 1. chaos & accident response

2. intensive reflections
3. restoring personal integrity
4. enduring the inquisition
5. obtaining emotional first aid
6. moving on

3 tiered support program for 2nd victims - 1. unit or dept based event recognition and support by trained colleagues or leaders (60% met)

2. trained peer support in high-risk clinical units to monitor, one-on-one support, trigger debriefings, and access to org resources (30%)
3. access to professional counseling (10%)

simulation training allows opportunity - 1. learn new skills

2. engage in deliberate practice
3. receive focused and real-time feedback

goal is to enable the accelerated dev of expertise (team and individual) bridging gap between classroom and real world in risk free env

systems approach - A holistic and analytical approach to solving complex problems that includes using a systems philosophy, systems analysis, and systems management

-most errors reflect predictable human failings in the context of poorly designed systems

-id situations or factors that likely to give rise to human error, and change the underlying systems of care in order to reduce the occurrence of errors or minimize their impact on pts

sharp end error - active error

adm the error

blunt end error - many layers that are not in contact with pt but influence the personnel and equipment at the sharp end

solutions for active and latent errors - active

• slips with attention for designs of protocols, devices, and work env (checklists, force functions, or minimize work arounds, remove variations, remove distractions, re-design)

-mistakes with more training, supervision

latent

-revise systems, protocols, how individuals interact with system

Team Strategies and Tools to Enhance Performance and Patient Safety - TeamSTEPPS

DOD and AHRQ

support effective communications and teamwork in healthcare

triggers - Targeted Injury Detection Systems

WSPEs - wrong site, wrong procedure, wrong patient errors

Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery - time out prior to all procedures

two approaches to problem of human fallibility - 1. the person (blame and shame)

2. they system approaches

advance health - One important route to restoring trust is through a commitment to transparency by all health care systems. Organizations and clinicians that act as though they have nothing to hide become more trustworthy. The health care system should seek to earn renewed trust not by hiding its defects, but by revealing them, along with making a relentless commitment to improve. The transition to openness is a difficult one for our often-beleaguered health care organizations, but it is

a journey worth making. In the longer run, access to information can inspire trust among patients and caregivers that the system is working effectively to ________________________.

Quality System Regulations - One of the goals of the FDA is to protect the health of the public by assuring that the practice of reprocessing and reusing single-use devices (SUDs) is safe and effective and based on good science. The FDA has designed an approach that applies existing regulations for original equipment manufacturers (OEMs) to third parties and hospitals to minimize risks associated with reprocessed SUDs. The public expects and the law requires all medical devices to be safe, effective, and manufactured in accordance with which of the following?

Four key aspects of the current context for health care delivery - 1. the growing complexity of science and technology,

2. the increase in chronic conditions,
3. a poorly organized delivery system,
4. constraints on exploiting the revolution in information technology

outmoded systems of work - Poor designs set the workforce up to fail, regardless of how hard they try

Censure and discipline - The high standards of practice that are taught to nurses, pharmacists, and physicians have often been reinforced in hospital practice by an unforgiving system of _____________________________________________________.

participant observer approach - co-workers are unaware that a study is taking place while another employee collects data

the delivery setting - Modifying training, regulatory, and legal environments is not a quick strategy for changing practice. These environments are closely interrelated with ________________.

Observers - used to double-check the accuracy of medication cart filling, filling new orders, and filling prescriptions.

incident report - legally recognized report of a medication error

These goals address identified problematic areas across health care. Patient safety is everyone's responsibility. Also, following NPSG's helps educate the community on how healthcare is promoting safety and seeking the prevention of injury. This should be done in every identified setting. - National Patient Safety Goals (NPSG)

An unexpected patient/resident occurrence that results in, or could result in, death or serious harm to the patient/resident. The purpose of reporting and investigating sentinel events is to improve the quality of patient/resident care by focusing attention on underlying causes and risk reduction and to increase the general knowledge about sentinel events, their causes and prevention. the reporting is not punitive. - A sentinel event

1. Independent, nonprofit organization with a mission to improve the safety of care for all patients.
2. Defines safety as the prevention of healthcare errors and the elimination or mitigation of patient injury caused by health care errors.
3. Health care errors are defined as an unintended health care outcome caused by a defect in the delivery of care to a patient. - National Patient Safety Foundation
4. Panel of widely recognized patient safety experts

a. Nurses, physicians, pharmacists, risk managers, clinical engineers, other professionals

2. They have hands-on experience in addressing patient safety issues in wide variety of health care settings.
3. The Patient Safety Advisory Group advises The Joint Commission on the development and updating of NPSGs.
4. Advises The Joint commission how to address emerging patient safety issues.

a. Ex. NPSG's, Sentinel Events Alerts, standards and survey processes, performance measures, educational materials, Center for Transforming Healthcare projects

5. Evaluate safety concerns and determine which ones will have the max impact for the minimum cost. - Patient Safety Advisory Group