1. Reducing Medical Errors, Promoting Patient Safety Sharon Levine, MD Associate Executive Director Kaiser Permanente October 20-21, 2008 Beijing, China Primum non nocere - Hippocrates Every Patient’s Right Everyone’s Responsibility

2. “Medicine used to be simple, effective and relatively safe - now it is complex, effective, and potentially dangerous” “Medicine used to be simple, effective and relatively safe - now it is complex, effective, and potentially dangerous” Sir Cyril Chantle Sir Cyril Chantle “ 44,000-98,000 patients die each year in hospitals from medical error” IOM report May be as high as 195,000 deaths per year Health Grades 2004 “ 44,000-98,000 patients die each year in hospitals from medical error” IOM report May be as high as 195,000 deaths per year Health Grades 2004 Our Challenge: Our Challenge: Preventing harm to patients from the care intended to help them Preventing harm to patients from the care intended to help them 2

3. Accidental Deaths in the U.S. (National Safety Council, Harvard School of Public Health, 1999) 3

4. How Do We Compare? 4

5. Top Patient Concerns About Hospital Stays Negative interaction of medications 58% Negative interaction of medications 58% Getting the wrong medications 61% Getting the wrong medications 61% Cost of treatment 58% Cost of treatment 58% Procedural complications 56% Procedural complications 56% Having enough drug information 53% Having enough drug information 53% Getting an infection during stay 50% Getting an infection during stay 50% Suffering from pain 49% Suffering from pain 49% 5

6. Basis Of Error– Complexity Powerful drugs Highly technical equipment/products Rapid decisions; time pressured Many care givers; multiple “handoffs” Task-based versus Systems- based Limited resources Complex human factors High acuity illness / injuries Environment prone to distraction flow Variable patient volume; variable patient flow Staff Management System Equipment/ Technology Environment Patien t 6 Requires more than “paying attention” and “trying hard”

7. 80% medical error is system derived 80% medical error is system derived 95% mistakes— the good guys 95% mistakes— the good guys Identify and address the human factors Identify and address the human factors Fix the system Fix the system Understand the difference Understand the difference Basis of Error - Complexity 7

8. “Culture of Safety” Awareness, understanding, and ownership of safety by all Awareness, understanding, and ownership of safety by all Constant vigilance to prevent error Constant vigilance to prevent error Learning from errors that do occur, and minimize chance of recurrence Learning from errors that do occur, and minimize chance of recurrence Teamwork, not hierarchy or autonomy Teamwork, not hierarchy or autonomy Communication and hand-offs Communication and hand-offs Non-punitive environment - encourage reporting of errors and near-misses Non-punitive environment - encourage reporting of errors and near-misses Systems to mitigate “human factors” Systems to mitigate “human factors” Memory capacity Memory capacity Mental processing Mental processing Stressors: fatigue, emergencies Stressors: fatigue, emergencies 8

9. Behavior Human error--inadvertently doing other than what should have been done; slip, lapse, mistake - console Human error--inadvertently doing other than what should have been done; slip, lapse, mistake - console At risk behavior - behavior where risk is not recognized, or is mistakenly believed to be justified - coach At risk behavior - behavior where risk is not recognized, or is mistakenly believed to be justified - coach Reckless behavior - conscious disregard of a substantial and unjustifiable risk – remedial, then disciplinary action Reckless behavior - conscious disregard of a substantial and unjustifiable risk – remedial, then disciplinary action David Marx Biggest barrier to preventing errors – punishing people for making mistakes 9

10. “Culture of Systems” From patient-specific to systems view From patient-specific to systems view Indentifying patterns of error Indentifying patterns of error Standardization where appropriate: processes, procedures, checklists, standardized orders Standardization where appropriate: processes, procedures, checklists, standardized orders Care team accountability for error identification and elimination Care team accountability for error identification and elimination Expert team vs. team of experts: communication, simulation, attention to hand-offs Expert team vs. team of experts: communication, simulation, attention to hand-offs 10

11. Reduce Hospital Mortality and Morbidity Infection Reduction Falls and pressure ulcers Early goal-directed therapy High Alert Medication Program Highly Reliable Surgical Teams Disease-specific care: AMI, HF, PN, SCIP, CVA, glucose control Anticipating end of life: Palliative Care, Advance Directives Access to alternative care settings: SNF, HH, rehab Goals Drivers Focus Areas & Initiatives Drivers of Hospital Mortality and Morbidity Evidence- Based Care Appropriate Care Setting No Needless Harm/Deaths 11

12. High Alert Medication Program High Alert Drug List High Alert Drug List Standardize: policies and procedures Standardize: policies and procedures Education, training and retraining Education, training and retraining No-interruption zone, -wear No-interruption zone, -wear Peer observations Peer observations Measure, monitor, feedback Measure, monitor, feedback Peer group: share learnings Peer group: share learnings Leadership focus, oversight Leadership focus, oversight 12

13. Zone MedRite The Zone is an area marked out in front of the PYXIS to signify a “no interruption” area. Use of tape is a common zone indicator in hospitals such as in the OR and Pharmacy 13

14. No Interruption Wear (NIW) is the tool that helps minimize interruptions during medication administration Worn ONLY during the Medication administration process Allows the nurse to be “interrupted” at appropriate times 14

15. Percentage change from 1 st mean (13.23 Jan to June ’06) to 2 nd mean (26.0) June to April ’07: 97% From April ’07: Days since last event: 445 and counting 15

16. From “Art to Science” – Translating Evidence into Benefit Clinical Research EvidenceImplementationBenefit REDESIGNING PROCESSES System Redesign for Safety: Highly Reliable Surgical Teams16

17. Clinical Research EvidenceImplementationBenefit System Redesign for Safety Check lists Teamwork Time-out Standardized orders Safety Summit Safety team in every OR Standardized orders Checklist for every role Observation/audit Debrief Simulation Training Report cards 17

18. Early Evidence of Benefit 40% reduction in surgical complications since 2001 40% reduction in surgical complications since 2001 From one surgery-related injury per 48 days (2003 to 2007) to one in 280 days (and counting) 2008 From one surgery-related injury per 48 days (2003 to 2007) to one in 280 days (and counting) 2008 Significant and sustained improvement: in abx use/time/duration (97%); normothermia (95%); beta blocker use (97%) Significant and sustained improvement: in abx use/time/duration (97%); normothermia (95%); beta blocker use (97%) 18

19. Early Evidence: Surgical Care Improvement Program (SCIP) SCIP Composite of Antibiotic Choice, Timing and Duration 100% 90% 80% 70% 60% 50% 40% Regional SCIP Performance Quarter 1 2008 SCIP Abx Timing: 96% SCIP Abx Choice: 98% SCIP Abx Duration: 95% Hair Removal: 99% Normothermia: 92% Beta Blocker: 97% VTE composite: 94% 19