1. Reducing medical error and increasing patient safety
Richard Smith
Editor, BMJ

2. What I want to talk about
A story
How common is error?
Why does error happen?
How should we think of error?
How should we respond?

3. A story

4. How common is error? Harvard Medical Practice Study
Reviewed medical charts of patients admitted to 51 acute care hospitals in New York state in 1984
In 3.7% an adverse event led to prolonged admission or produced disability at the time of discharge
69% of injuries were caused by errors

5. How common is medical error?
Australian study
Investigators reviewed the medical records of admissions to 28 hospitals in New South Wales and South Australia in 1995.
An adverse event occurred in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9%
51% of adverse events were considered to have been preventable.

6. How common is medical error?
The differences between the US and Australian results may reflect different methods or different rates
Other, smaller studies (including one from Britain) show similar orders of errors
There are few studies from outpatients or primary care

7. How common is medical error?
An evaluation of complications associated with medications among patients at 11 primary care sites in Boston.
Of 2258 patients who had had drugs prescribed, 18% reported having had a drug related complication, such as gastrointestinal symptoms, sleep disturbance, or fatigue in the previous year.

8. Results of medical error
In Australia medical error results in as many as unnecessary deaths, and more than patients become disabled each year.
In the United States medical error results in at least (and perhaps as many as ) unnecessary deaths each year and excess injuries.

9. Types of error
About half of the adverse events occurring among inpatients resulted from surgery.
Next come
Complications from drug treatment
therapeutic mishaps
diagnostic errors were the most common non-operative events. In the Australian study cognitive errors, such as making an

10. Types of error
Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.

11. Which patients are most at risk?
Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery
Those with complex conditions
Those in the emergency room
Those looked after by inexperienced doctors
Older patients

13. How dangerous is health care?
Less than one death per encounters
Nuclear power
European railroads
Scheduled airlines
One death in less than but more than 1000 encounters
Driving
Chemical manufacturing
More than one death per 1000 encounters
Bungee jumping
Mountain climbing
Health care

14. Why do errors happen?
All humans make errors: indeed, “the ability to make mistakes” allows human beings to function
Most of medicine is complex and uncertain
Most errors result from “the system”--inadequate training, long hours, ampoules that look the same, lack of checks, etc
Healthcare has not tried to make itself safe

16. How to think of error?
An individual failing
Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis
It will not solve the problem--it will probably in fact make it worse because it fails to address the problem
Doctors will hide errors
May destroy many doctors inadvertently (the second victim)

17. How to think of error? A systems failure
This is the starting point for redesigning the system and reducing error

18. How to respond? Tactics Reduce complexity
Optimise information processing
checklists, reminders, protocols
Automate wisely
Use constraints
for instance, with needle connections
Mitigate the unwanted side effects of change
with training, for example.

19. Building a safe healthcare system (from James Reason)
Principles
Policies
Procedures
Practices

20. Building a safe healthcare system (from James Reason)
Principles
Safety is everybody’s business
Top management accepts setbacks and anticipates errors
safety issues are considered regularly at the highest level
Past events are reviewed and changes implemented

21. Building a safe healthcare system (from James Reason)
Principles
After a mishap management concentrates on fixing the system not blaming the individual
Understand that effective risk management depends on the collection, analysis, and dissemination of data
Top management is proactive in improving safety--seeks out error traps, eliminates error producing factors, brainstorms new scenarios of failure

22. Building a safe healthcare system (from James Reason)
Policies
Safety related information has direct access to the top
Risk management is not an oubliette
Meetings on safety are attended by staff from many levels and departments
Messengers are rewarded not shot
Top managers create a reporting culture and a just culture

23. Building a safe healthcare system (from James Reason)
Policies
Reporting includes qualified indemnity, confidentiality, separation of data collection from disciplinary procedures
Disciplinary systems agree the difference between acceptable and unacceptable behaviour and involve peers

24. Building a safe healthcare system (from James Reason)
Procedures
Training in the recognition and recovery of errors
Feedback on recurrent error patterns
An awareness that procedures cannot cover all circumstances; on the spot training
Protocols written with those doing the job
Procedures must be intelligible, workable, available

25. Building a safe healthcare system (from James Reason)
Procedures
Clinical supervisors train their charges in the mental as well as the technical skills necessary for safe and effective performance

26. Building a safe healthcare system (from James Reason)
Practices
Rapid, useful, and intelligible feedback on lessons learnt and actions needed
Bottom up information listened to and acted on
And when mishaps occur
Acknowledge responsibility
Apologise
Convince patients and victims that lessons learned will reduce chance of recurrence

27. James Reason’s bottom line
Fallibility is part of the human condition
We can’t change the human condition
We can change the conditions under which people work

28. Conclusions Human beings will always make errors
Errors are common in medicine, killing tens of thousands
We begin to know something about the epidemiology of error, but we need to know much more
Naming, blaming and shaming have no remedial value

29. Conclusions
We need to design health care systems that put safety first (First, do no harm)
We know a lot about how to do that
It’s a long, never ending job