Healthcare Errors Error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. By IOM

Healthcare Errors  Errors or mistakes committed by health professionals which result in harm to the patient. They include errors in diagnosis (DIAGNOSTIC ERRORS), errors in the administration of drugs and other medications (MEDICATION ERRORS) and errors in the performance of surgical procedures,,etc 

MEDICAL ERRORS are differentiated from MALPRACTICE in that the former are regarded as honest mistakes or accidents while the latter is the result of negligence, reprehensible ignorance, or criminal intent.

Causes

Poor doctor handwriting Poor doctor instructions Failure or delay of patent to report symptoms and medications. Failure to report other alternative medicines they are taking Non-compliance of patient with treatment plan

Fear of legal issues: e.g. failure to admit to taking illicit drugs Fear of social issues: e.g. failure to admit to lifestyle or social habits. Fear of doctor's scolding: e.g. failure to admit to not following treatments. Patient pressure: the tendency to push the doctor for certain treatments Failure to read medication labels and instructions fully Wrong medication dispensed

Similarly labeled or packaged medications wrongly given. Similarly named medications confused (by doctor or pharmacist) Wrong dosage dispensed Failure to communicate instructions on taking medication Nosocomial infections Wrong patient surgery Wrong site surgery: e.g. surgery on the wrong organ

Results of Healthcare Errors  Fatal errors could lead to patient's death  Errors may make the patient worse  Bad Reputation of the hospital and medical staff  Wasting of time, effort and money  Misdiagnosis of diseases

WHAT IF an ERROR HAPPENED !!! “7 Steps”

1. CARE: Take Care of the PatienT Address Current Health Care Needs Obtain Necessary Consults Assign Primary Responsibility for Care and Communicate the Identity of the Primary Physician and the Physician's Contact Information to Family and Health Care Team

2. PRESERVE: Preserve the Evidence Sequester Machinery (Pumps, Anesthesia Machines) and Preserve Settings Sequester Equipment (Syringes, IV Tubing, Medication Vials) Inform Hospital Risk Manager Inform Maintenance Department or Supplier Acquire Back-up Equipment

3. DOCUMENT: Document in the Medical Record What to Include: "Known Facts" About Unanticipated Outcome Care Given in Response Disclosure Discussion and Names of Witnesses (see Step 5 ). Treatment and Follow-up Plans

3. DOCUMENT: Document in the Medical Record What Not to Include: Subjective Feelings or Beliefs Speculation or Blame References to Incident Report Forms or Event Analysis “Confidential” Information

3. DOCUMENT: Document in the Medical Record  Begin the Event Analysis by Completing An Incident Report  Communicate “Known Facts”  Avoid Speculation or Blame  “Confidential” Document  Do Not Place in Medical Record or Discuss in Medical Record  Do Not Photocopy

4. REPORT: Complete Mandatory Reports If Required Inform Hospital Risk Management. Inform Public Health Department and/or Other Governmental Agencies

5. DISCLOSE The Initial Disclosure Discussion Why, Who, When, Where?

DISCLOSE  Why Disclose Unanticipated Outcomes?  Patient Has Right to Know Condition and Make Health Care Decisions  Improves Doctor/Patient Relationship  Rebuilds Trust  Quality of Care  Professional Code of Ethics  Standard on Patient Safety and Error Reduction8  May Be Required by Hospital Staff By-Laws, Medical Group Policies and  Procedures, Health Plans, and Health Care Organizations

DISCLOSE  Who Will Inform Patient?  Health Care Provider(s) Involved in the Unanticipated Outcome  Provider(s) With Responsibility for Ongoing Care  Person(s) With Ability to Answer Questions  Persons Involved in Disclosure Discussion May Need Assistance in  Preparing, Coordinating or Conducting Discussion, Depending Upon:  Communication Skills  Rapport with Patient and Family  Language Barriers

DISCLOSE  When to Inform Patient and Family?  As soon as Practicable After Immediate Health Care Needs Addressed  Consider Patient’s Physical and Emotional Readiness  Patient’s Permission Needed to Discuss Care with Family  Where to Hold Discussion  Consider Privacy and Health Needs

DISCLOSE How To Disclose Unanticipated Outcomes Express Empathy Convey Compassion for Patient’s and Family’s Pain and Suffering “I’m sorry that you…” of “I am sorry for your…” Focus on Patient’s and Family’s Needs Avoid “I am sorry that I…” Avoid Speculation and Blame Solicit and Respond to Patient’s/Family’s Feelings and Questions Respond to Patient’s Complaints Plan for Follow-up Care and More Discussions and Communicate the Plan

6. ANALYZE: Analyze Unanticipated Outcome to Prevent Recurrence and/or Improve Outcome

7. HEAL: Heal the Health Care Team Acknowledge Effect on Health Care Team Members Unanticipated Outcomes Disturbing to All Involved Identify Resources to Help in Healing Allow Time for Resolution of Feeling

Improving Patient Safety  Research funded by AHRQ and others has been important in identifying the extent and causes of errors. Now, additional research is needed to develop and test better ways to prevent errors, often by reducing the reliance on human memory. Some areas of past research that have shown promise in helping to reduce errors include computerized ADE monitoring, computer-generated reminders for followup testing, and standardized protocols

Thank you presented by : Ibraheem al jazei

REFRENCES