Prevention of Medical Errors Kyle B Riding, PhD, MLS(ASCP)CM Assistant Professor of Medicine University of Central Florida

Objectives: 1. State the impact medical errors have on patient health and financial outcomes 2. Describe the rationale and process of root cause analysis along with the six aims of patient safety as proposed by the IOM 3. Explain how laboratory professionals can be involved in preventing medical errors

Ice Breaker Activity Break into groups of 3-5 people Pick a member to be the scribe Spend the given time discussing the most common errors you see in your facility The scribe should write each of these down on their own post card Save the post cards….we will come back to those in a little bit!

Why do we need to care about Medical Error Prevention? A 2017 survey found that 21% of Americans personally experience a medical error (IHI/NORC) Data place medical errors as the third leading cause of premature death in the United States Estimated 250,000-400,000 premature deaths Direct costs are estimated at about $20 billion/year Apply ten quality adjusted life years for each premature death and this becomes $180-200 billion/year This represents ~40% of annual Medicare expenditures

Defining Medical Errors Grober and Bohnen (2005) defined medical errors as: “An act of omission or commission in planning or execution that contributes or could contribute to an unintended result.”

Defining Medical Errors Grober and Bohnen’s definition is derived from comparing two views on what defines error: Outcome-driven viewpoint on error Focus is on adverse outcomes Historically preferred in medical community Process-driven viewpoint on error Focus is on process errors that could lead to adverse outcomes Generally, we look at process versus strictly outcomes now

Swiss Cheese Model This Photo by Unknown Author is licensed under CC BY-SA-NC Originally conceptualized by Dr. James Reason and demonstrates how process failures can lead to adverse outcomes for patients

Lippi, Bowen, & Adcock (2016)

Dawson, J 2013

Common Medical Errors What are common errors? Misdiagnosis or delayed diagnosis Medication errors/Inappropriate medication use Healthcare associated infections Falls while in medical care Poor communication to the patient Procedure performed incorrectly or without need

Addressing Medical Errors To address these medical errors the IOM recommended that care be: Safe Effective Efficient Timely Patient-Centered Equitable These six recommendations have been around for the last 20 years…still an issue.

Safe Care Avoiding harm to patients from the care that is intended to help them What is a laboratory-related scenario where there can be a lack of SAFE care?

Effective Care Providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit avoiding underuse and misuse, respectively. What is a laboratory-related scenario where there can be a lack of EFFECTIVE care?

Patient-Centered Care Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions. What is a laboratory-related scenario where there can be a lack of PATIENT-CENTERED care?

Timely Care Reducing waits and sometimes harmful delays for both those who receive and those who give care. What is a laboratory-related scenario where there can be a lack of TIMELY care?

Efficient Care Avoiding waste, including waste of equipment, supplies, ideas, and energy. What is a laboratory-related scenario where there can be a lack of EFFICIENT care?

Equitable Care Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. What is a laboratory-related scenario where there can be a lack of EQUITABLE care?

Root Cause Analysis When investigating medical errors, it is important to look at the bigger picture surrounding the error To determine the ultimate cause(s) of the problem, you must analyze the following: Equipment Process People Materials Environment Management

Bad Coffee RCA Example https://commons.wikimedia.org/wiki/File:Fishbone_BadCoffeeExample.jpg

CIA Model Issues we can: Examples: Control Influence Accept Control: Mislabeled/Unlabeled & Hemolyzed Samples Influence: Over or under utilization, IT Issues Accept: Delayed TAT (?instrument, ?patient)

Elephants in the room Control Influence Accept

Thank you! Kyle.Riding@ucf.edu