1. Lecture 6: error in healthcare Dr Carl Thompson, Department of Health Sciences, University of York, UK

2. Why worry about decision making and judgement? They contribute to They contribute to health gain health gain Mortality and morbidity Mortality and morbidity Professional power Professional power Patient involvement Patient involvement Decisions and Judgements are the ‘black box’ in healthcare. Decisions and Judgements are the ‘black box’ in healthcare. Boundaries and the ball park are shifting Boundaries and the ball park are shifting

3. The good news Given conditions of irreducible uncertainty most decisions are good enough Given conditions of irreducible uncertainty most decisions are good enough People apply the same rules to professional decision making as they do in real life – this is a good thing! People apply the same rules to professional decision making as they do in real life – this is a good thing!

4. The Bad News Within unavoidable events in healthcare are avoidable events Within unavoidable events in healthcare are avoidable events Cognitive shortcuts lead to systematic errors… Cognitive shortcuts lead to systematic errors… Simply relying on clinical experience is not enough Simply relying on clinical experience is not enough

5. Does bad judgement matter? USA 44-98,000 deaths – “To Err is Human” USA 44-98,000 deaths – “To Err is Human” Australia 250,000 adverse events Australia 250,000 adverse events 50,000 permanent disability 50,000 permanent disability 10,000 deaths “Iatrogenic Injury in Australia” 10,000 deaths “Iatrogenic Injury in Australia” Denmarkconfirmed 9% of admissions Denmarkconfirmed 9% of admissions N.Z. confirmed 10% of admissions N.Z. confirmed 10% of admissions UK11% of admissions UK11% of admissions 850,000 adverse events 850,000 adverse events deaths & permanent disability deaths & permanent disability Between 7 and 8.4 additional bed days per adverse event Between 7 and 8.4 additional bed days per adverse event

6. definitions Adverse event: an event or omission arising during clinical care and causing physical or psychological injury to a patient Adverse event: an event or omission arising during clinical care and causing physical or psychological injury to a patient Error: the failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given aim. Error: the failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given aim.

7. Some ‘classic’ adverse events 1 A hospital patient collapsed after a nurse gave her antibiotic tablets crushed in water via and intravenous drip. Only special fluids can be given via an intravenous drip. Similarly, antibiotics and other drugs can only be given in specially prepared solutions and not though the impromptu crushing of tablets. The patient was rushed to intensive care and subsequently recovered. NHSE

8. Some ‘classic’ adverse events 2 A premature baby girl died after being given an excessive dose of morphine – 15mg instead of 0.15mg – due to miscalculation of the dosage. The dose was calculated by the senior house officer, checked by a nurse and administered by the senior registrar. NHSE

9. Some ‘classic’ adverse events 3 A man admitted to hospital for an arthroscopy on his knees had a previous history of thrombosis. This was noted by a nurse on his admission form, but was not entered on the operation form which had a section for risk factors and known allergies. The operation was carried out and the patient was discharged from hospital the same day. Given his history of thrombosis the patient should have been given anticoagulant drugs following his operation, but because his history had not been properly recorded none were given. Tow days later he was admitted to the intensive care unit of another hospital with a blood clot in his lungs. MPS Casebook, 13, 1999

10. Why do they happen… Was there a prior intention to act? Was there intention in action? Involuntary or no intentional action Spontaneous or subsidiary action Did the actions proceed as planned? Unintentional action (slip or lapse) Did the actions achieve their desired end? Intentional but mistaken action Successful action No Yes

11. Making sense of error 2 main approaches 2 main approaches Person centred Person centred System System

12. Person centred approaches Skills based Skills based Rules based Rules based Knowledge based (more on this next week) Knowledge based (more on this next week)

13. Skills based failure Inattention Inattention Double capture Double capture Omission post interruption Omission post interruption Reduced intentionality Reduced intentionality Perceptual confusion Perceptual confusion Interference errors Interference errors

14. Rules based failure Misapplication of good rules Misapplication of good rules 1 st exceptions 1 st exceptions Countersigns Countersigns Informational overload Informational overload Rule strength Rule strength General rules Redundancy Rigidity Application of bad rules Encoding deficiencies Action deficiencies

15. Systems approaches Holistic stance Holistic stance Recognises complexity, vagueness and interaction Recognises complexity, vagueness and interaction Errors shaped by upstream systemic factors (strategy, culture and risk approach) Errors shaped by upstream systemic factors (strategy, culture and risk approach) Counter measures based on assumption that human-condition immovable so change work conditions Counter measures based on assumption that human-condition immovable so change work conditions Swiss cheese approach, active failure and latent conditions Swiss cheese approach, active failure and latent conditions

16. Some holes due to active failure (mistakes or procedural violations) Other holes due to latent conditions (e.g. faulty equipment, lack of staff, training or experience) Successive layers of defences, barriers and safeguards Reason 1997

17. Active failure Unsafe acts committed by those at the sharp end. Unsafe acts committed by those at the sharp end. Slips, lapses or procedural violations Slips, lapses or procedural violations Immediate and (usually) short-lived impact on the defensive layers Immediate and (usually) short-lived impact on the defensive layers Often the focus of subsequent investigations Often the focus of subsequent investigations

18. Latent conditions ‘resident pathogens’ ‘resident pathogens’ Organisations embed preconditions for failure Organisations embed preconditions for failure Sources: designers, builders, procedure writers and top management. Sources: designers, builders, procedure writers and top management. ‘seed’ pathogens into system (good ones as well) ‘seed’ pathogens into system (good ones as well) ‘swatting mosquitos’ ‘swatting mosquitos’ Hard to address as whilst easily visible, change involves addressing core values and beliefs. Hard to address as whilst easily visible, change involves addressing core values and beliefs.

19. Some holes due to active failure (mistakes or procedural violations) Other holes due to latent conditions (e.g. faulty equipment, lack of staff, training or experience) Successive layers of defences, barriers and safeguards Reason 1997

20. exercise Look at the (pre) chronology of an accident Look at the (pre) chronology of an accident Try and classify the kinds of errors that are described Try and classify the kinds of errors that are described Try and work out if they are slips, lapses, mistakes and what the active and/or latent factors might be. Try and work out if they are slips, lapses, mistakes and what the active and/or latent factors might be.