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

2. 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

3. 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!

4. 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 premature deaths
Direct costs are estimated at about $20 billion/year
Apply ten quality adjusted life years for each premature death and this becomes $ billion/year
This represents ~40% of annual Medicare expenditures

5. 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.”

6. 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

7. 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

9. Lippi, Bowen, & Adcock (2016)

10. Dawson, J 2013

11. 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

12. 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.

13. 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?

14. 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?

15. 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?

16. 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?

17. 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?

18. 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?

19. 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

20. Bad Coffee RCA Example

21. 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)

22. Elephants in the room
Control Influence Accept

23. Thank you! Kyle.Riding@ucf.edu