1. Impact of Human Error in Software Aided Patient Management Andy Letheren Principal Consultant RM Consultants

2. What do we mean by ‘Risk’? 4 “A chance or possibility of danger, loss, injury or other adverse consequence” Concise Oxford Dictionary 4 Obliged to reduce risk to as low a level as is reasonably practicable 4 “Acts of God” do occur – Risk is NEVER zero

3. Sources of Risk Patient Underlying Condition Computer Errors Lifestyle factors Human Errors

4. Schematic Representation of Risk Probability of at Least One Error Number of Patients

5. Use of Software Reduces Risk Probability of at Least One Error Number of Patients

6. Printer Reduces Transcription Errors Probability of at Least One Error Number of Patients

7. Independent Checking Further Reduces Risk Probability of at Least One Error Number of Patients

8. Modelling Human Error Incorrect Information OR AND Incorrect Instruction Generated in Clinic Independent Check Fails High change in INR not recognised Clinic determines incorrect dosing instruction Clinic Misassigns patient record

9. ‘Doing the Sums’ 4 Industry Standard methodology – HEART 4 Assign a ‘generic ‘ probability of error then increase to account for factors such as: –Inexperience –Time Pressure –Sleep Disruption –Absence of checking 4 Combine the calculations – Add for ‘OR’, multiply for ‘AND’

10. Results – the numbers 4 All assume clinic with 2000 patients 4 Predicted likelihood of a serious error causing patient harm (only 1 in 100 errors is serious): –‘All manual clinic’: 1 in 700 patient years –Software, manual label printing or telephone: 1 in 1000 patient years –Software, book printer or direct letter: 1 in 2000 patient years –Software, manual printing, with check: 1 in 700,000 patient years –Software, book printer or direct letter, with check: 1 in 1,400,000 patient years

11. Incorrect Information Risk = p4 * p5 AND Results – Combining Probability Incorrect Instruction Generated in Clinic Risk= p4 = p1 + p2 + p3 Independent Check Fails Risk = p5 OR High change in INR not recognised Risk = p1 Clinic determines incorrect dosing instruction Risk = p2 Clinic Misassigns patient record Risk = p3

12. Target Setting 4 HSE (UK Health and Safety Executive) believe that the following risks of death are considered ‘broadly tolerable’ by the UK population –Worker in high risk industry 1 in 1000 person years –Road traffic accident 1 in 10,000 person years –Industrial accident in safest parts of industry 1 in 100,000 person years

13. Points to Consider 4 What level of risk is present in your clinic? 4 Can you reasonably do anything to reduce risk? 4 Are you adopting best practice?

14. Conclusions and Way Forward 4 Use of Software Reduces Risk – Error messages give support – make sure that these are understood and acted upon 4 Book Printer or Direct Letter Reduces Transcription Errors – Consider whether your system is robust against assigning right info to wrong patient or vice versa 4 Independent Checking Further Reduces Risk – confirm that your checking procedure is adding value