Objectives By the end of this session you will be able to: explain the term ‘error’ explain why errors are made describe individual strategies to reduce the frequency of errors

Patient Safety and the Australian Curriculum Framework for Junior Doctors

Adverse events in health Contribute to about 18,000 deaths per year in Australia (approximately 10 times the road toll) Occur in up to 16% of all hospital admissions Quality in Australian Healthcare Study (Wilson et al. MJA 1995) Ice Breaker Click to view video

Have you made any silly mistakes recently? What happened? What were the consequences?.....

What is an “error”? “ Doing the wrong thing when meaning to do the right thing ” (Runciman) A more formal definition is: (Reason) “planned sequences of mental or physical activities that fail to achieve their intended outcomes, when these failures cannot be attributed to the intervention of some chance agency”

Error and outcome Error and outcome are not inextricably linked –Harm can befall a patient in the form of a complication of care without an error having occurred 1 –Many errors occur that have no consequence for the patient either due to a timely intervention (eg clinical pharmacist intercepting wrong dose) or due to chance (QAHCS – 75% of incidents had an element of ‘human error’)

Basic principles about error 1.We all make errors all the time 2.The same error (even minor ones) can have different consequences 3.Errors are not bad or morally wrong – BUT Healthcare workers expect perfection of themselves (and colleagues) AND We often ascribe blame to individual without looking at wider circumstances Adapted from Queensland Health Human Error and Patient Safety Training (HEAPS)

In hospitals the effects of small errors can be large!

Outcome Definitions Clinical incident Near miss (or ‘no-harm incidents’) Adverse event (or ‘harm incidents’) Harm Sentinel event Clinical incidents = Near misses (90%) + Adverse events (10%)

Reason Types of errors

Slips - I put salt in my tea not sugar… Lapses - I was interrupted and forgot to take the document out of the copier… –Usually repetitive actions Mistakes - I thought the problem was hypovolaemia but it was cardiogenic shock… –Wrong plan or action Types of errors

Courtesy P. Croskerry

Why do we misinterpret things sometimes? Because the human brain is so…. Good at finding shortcuts (fast) Good at filtering information Good at making sense of things Usually this is a good thing, sometimes it fools us Error is the “downside to having a brain”!

The environment can “set us up” to make errors look-alike and sound-alike pharmaceuticals equipment design – e.g. defibrillators user interfaces – e.g. infusion pumps

Situations leading to error: The “Three Bucket” model Poor knowledge Fatigue Little experience Feeling ill Distraction Inadequate handover Production pressure Equipment failure Variation from “normal” Omission errors Unfamiliar equipment Reason 2004

VIDEO Watch this video of a “typical day” in the emergency department How did the mistakes come about? Were they inevitable or avoidable? Faultlines part 1 Click to view video. Do not interrupt video once started. Let video run through its entirety.

VIDEO What circumstances have you noticed so far that may contribute to an error? What strategies is the junior doctor using to minimise these factors? Faultlines part 2 Click to view video. Do not interrupt video once started. Let video run through its entirety.

What were the contributing factors in this case? Poor knowledge Fatigue Little experience Feeling ill Distraction Inadequate handover Production pressure Equipment failure Variation from “normal” Omission errors Unfamiliar equipment Reason 2004

Performance-shaping factors IIllness MMedication –prescription, alcohol & others SStress AAlcohol FFatigue EEating Am I safe to work today?

Stress and Performance The Relationship Between Stress and Performance Stress Level Area of “Optimum” Stress Low Stress Boredom High Stress Anxiety, Panic Performance Level

Stress and Performance

Don’t forget …. If you’re – H ungry – A ngry – L ate or – T ired ….. HALTHALT

Personal error reduction strategies Know yourself –eat well, sleep well, –look after yourself … Know your environment Know your task Preparation & planning –“What if …?” Build ‘checks’ into your routine Speak up if you don’t know!

Systems problems May be inadequate staffing, too busy etc. Design of equipment makes it difficult to do the right thing Difficulties working as a team No or patchy orientation Often no clear accountability No ‘standard operating procedures’ Culture which allows unacceptable behaviours

Communication and Teamwork Be precise with your communication –Use clinical terms not social speak Practice effective handovers Encourage ‘read-back’ of important information –eg. Confirming instructions or drug doses if given over the telephone Remember to have structured briefings (‘Time outs’) before procedures Have a structure and plan what you need to say…

Education package available from PMCV and Southern Health

Mental preparedness Getting the balance right Assume that errors can and will occur Identify those circumstances most likely to lead to error Have contingencies in place to cope with problems, interruptions and distractions – discuss them aloud with your team Mentally rehearse complex procedures

Technology New technology doesn’t solve the problems New technology makes new problems or can even make old problems even worse!

New technology makes new errors… Mis-programming (eg. 10-fold or decimal point errors) Risks of malfunction, battery failure, ignoring alarms etc. OR Errors in counting drops per minute Risk of unnoticed occlusion

Summary Making errors is an inevitable part of the human condition - it’s how we’re built! Be aware of yourself, the context and the task – ask: –“what are the risks?” –“what are the ways to minimise the risk?” Communicate effectively and use your team – they are your eyes and ears