1. Systems Analysis of Errors Debora Simmons, PhD, RN, CCNS

2. What is a Systems Approach? Humans are fallible and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in "upstream" systemic factors. Reason, 2000

3. What is a System? A set or group of interacting, interrelated or interdependent elements or parts that are organized and integrated to form a collective unity or a unified whole to achieve a common objective Reason,1990

4. Systems of the body  Interdependent – lung-heart- kidney  Interactive –vascular-heart-kidney

5. Active : Occur at a set point and consequences are readily apparent Latent Errors- Are delayed reactions and are consequences of decisions made away form the point of impact System Failures James Reason

6. B James

7. A Path to Failure Latent Current Active Failures Conditions Failures Defenses ACCIDENTACCIDENT Cognitive Failures (Memory Lapses) Slips Mistakes Workload Equipment Knowledge Ability Environment Manufacture Design Management Decisions Policy

8. van der Schaff- modified for healthcare Technical Organizational Human Factors Adequate defenses Return to Normal Developing Errors Near Miss Dangerous Situation Dangerous Situation ERROR (Inadequate Defenses)ERROR (Inadequate Defenses)

9. The Cause and Effect Principle

10. #1 Cause and Effect Cause and effect are the same thing  Differ by how we perceive them in time EffectsCauses InjuryCaused ByFall Caused ByWet Surface Caused ByLeaky Valve Caused BySeal Failure Caused ByNot Maintained

11. #2 Cause and Effect Cause and Effect are part of a continuum of causes  A Primary Effect is the effect of a consequence that we want to prevent from occurring

12. Cause and Effect # 3 Each effect has at least two causes in the form of actions and conditions  Actions are momentary causes that bring conditions together to cause an effect  Conditions are causes that exist over time prior to an action Primary Effect Action Condition By

13. Cause and Effect Principle #4  An effect exists only if its causes exist at the same point in time and space  You have to have: the action and the conditions

14. Cause and Effect Principle # 5  There is never one cause

15. Problem Solving Using C/E  Identify causal relationships and control one or more of the causes to affect the problem in a way that meets the objectives  Understand the problem  Use an effective tool set

16. Classic If people are more careful, pay attention, are more detailed there will be a decrease in errors (My Mother)

17. New It is the design of objects, activities, procedures patterns of behavior that result in error Norman and Reason

18. Human Factors Analysis Properties of Memory Decision Making Information Environment Physical

19. Error is Inevitable Because of Human Limitations  Limited memory capacity  Limited mental processing capacity  Negative effects of stress - Tunnel vision  Negative influence of fatigue and other physiological factors  Limited ability to multitask  Flawed teamwork

20. Systems of Care  > 80 % medical error is system derived  95 % of mistakes are made by the good guys like you and me  Finding the “Bad Apples” and fixing them doesn’t work – there aren’t enough  The system solution – make it hard to do the wrong thing

21. Nurse inadvertently connected a feeding of expressed breast milk to an intravenous line

22. IV tubing connected Connector for NGT ( feeding tube)

23. connected IV tubing

24. IV tubing connected Connector for NGT (feeding tube)

25. Syringe used for feeding

26. Syringe Pump used for IV infusions and Feeding through NGT

27. 27

29. 29 Central Venous Catheter Gastrostomy Tube Arterial Catheter Epidural Catheter 2/7/00

30. Literature Search First documented misconnection – 1972 (Wallace) © 2006 Simmons & Graves

31.  Joint Commission  Institute for Safe Medication Practices  Food and Drug Administration  American Nurses Association  American Association Medical Instrumentation - 1996 and 2005  International Standards Organization  World Health Organization  California Bill 2013 deadaline  ADvaMED Tubing misconnections

32. A review by USP of more than 1200 cases:  Intravenous infusions connected to epidural lines, and epidural solutions (intended for epidural administration) connected to peripheral or central IV catheters.  Bladder irrigation solutions using primary intravenous tubing connected as secondary infusions to peripheral or central IV catheters.  Infusions intended for IV administration connected to an indwelling bladder (foley) catheter.  Infusions intended for IV administration connected to nasogastric (NG) tubes.  Intravenous solutions administered with blood administration sets, and blood products transfused with primary intravenous tubing.  Primary intravenous solutions administered through various other functionally dissimilar catheters, such as external dialysis catheters, a ventriculostomy drain, an amnio-infusion catheter, and the distal port of a pulmonary artery catheter.

33. Tubing Misconnections: Normalization of Deviance Debora Simmons, Lene Symes, Peggi Guenter, and Krisanne Graves (Nutr Clin Pract. 2011;26:286-293) Case reports N =116 Adult (N=60) Child/infant (N=30) Not Specified (NS) (N=26) Patient Outcome from 116 cases Death (N=21) Survival: Hypersensitivity and Hypercoagulopathy reaction (N=1) Septicemia/sepsis (N=16): 2 with neurologic damage 2 with respiratory arrest 33 with hypoxia 1 with seizure & hypoglycemia 5 with intracranial hemorrhage Renal impairment (N=8) Respiratory arrest/distress (not listed above) (N=2) Neurologic damage (not listed above) (N=2), 1 with blindness & deafness No harm, or outcome not given (N=12)

34. Enteral to Respiratory or Respiratory to Enteral

35.  Majority = Blood pressure monitors to Intravenous lines Gas to Intravenous line

36.  Infusion and monitoring systems in healthcare are physiologically not compatible – many cause death if accidently connected to another  Infusion systems rely upon a single, universal connector- the luer tip/small bore connector  Routine tasks such as connecting tubing are at risk for “automatic mode errors” Connecting Tubing - a high risk activity

37. Nurses’ Understanding of Tubing Misconnections between Enteral and Intravenous Systems: a multiple case, explanatory, grounded theory study July 6, 2011

38. What do nurses understand about tubing misconnections between enteral and intravenous systems?

40. Findings Cognitive Constructs  Nurses have a wide variation in their knowledge regarding the occurrence of tubing misconnections.  Limits on human ability, factors that nurses cannot control, and characteristics of the nurse, patient, and family may contribute to tubing misconnections.

41. Findings Work Environment  Multiple organizational practices do not support the mental work of nurses.  Healthcare has not applied common safety concepts to the work environment. Technical Properties  Some nurses rely on physical attributes of attributes of devices to cue them to make tubing connections. Others report that relying on such cues may lead to misconnections.

42. Future Research Cognitive Constructs  Nursing education research : How do you imbed generic safety knowledge within the nursing workforce?  How can we improve human (nursing) ability to provide safe and effective patient care in the face of complexity in healthcare? Work Environment  How can the work environment and organizational practices be modified to support the work of nurses? Technical Properties  How do nurses’ attach meaning to common medical devices and tasks?  What design features of healthcare devices support nurses’ cognitive work?

43. “This label has a good purpose.” “This label is stupid.” Variation in Understanding safety

44. Overarching Conclusions  Nurses do not conceptualize making a tubing connection as a linear process.  Nursing has not assimilated basic safety principles into practice.  Factors related to the cognitive constructs of nurses, the work environment, and technology properties are pervasive and create an environment that may be deadly for patients.

45. Human Factors the study of interrelationships between humans, the tools they use, and the environment in which they live and work  Used to design safer and more effective systems  Commonly used in industry (aviation,nuclear,chemical,production)  Used in critical incident analysis - 9/11, Chernobyl, Challenger, Three Mile Island

46. Human Factors  Cognitive  Behavioral  Individual  Industrial  Organizational  Cultural How do we make healthcare errors?

47. Cognitive Psychology :The way we think and problem solve 1) Planning - gather information 2) Storage – process information 3) Execution – make a decision

48. Memory  Ability to store, retain, and subsequently recall information  Three main stages in the formation and retrieval of memory: – Encoding (processing and combining of received information) Encoding – Storage (creation of a permanent record of the encoded information) Storage – Retrieval/Recall (calling back the stored information in response to some cue for use in some process or activity) Retrieval/Recall

49. Sensory Associations to Memory  Tying ribbon or string around a finger is the iconic mnemonic device for remembering a particular thought, which one consciously trains oneself to associate with the string.

50. Error Modes Automatic Mode  Slips  Lapses Non Automatic Mode  Mistakes

51. Automatic Mode – the state of mind where familiar actions take place effortlessly  Unconscious actions  Are frequent in common familiar tasks  Can not be escaped

52. Automatic Mode: Slips- errors that occur during familiar actions and are governed by familiar impulses incorrect execution of a planned action occur when you automatically do something that you didn't mean to do (Locking the keys in the car)

53.  Habit  Interruptions  Hurry  Fatigue  Anger  Anxiety  Boredom  Fear Causes of Slips and Lapses

55. Please comment  FDA Issues Feeding Tube Misconnection Guidance Document  To help combat the deadly problem of tubing misconnections, the U.S. Food... manufacturers weigh the risk of small-bore connectors for enteral feeding tubes. www.aami.org/news/2012/073012_connector.html

56. Van Der Shaf- modified for healthcare Technical Organizational Human Factors Adequate defenses Return to Normal Developing Errors Near Miss Dangerous Situation Dangerous Situation ERROR (Inadequate Defenses) ERROR (Inadequate Defenses)

57. Managing Risk – The Three Behaviors David Marx Reckless Behavior Intentional Risk-Taking Manage through:  Disciplinary action At-Risk Behavior Unintentional Risk-Taking Manage through:  Understanding our at- risk behaviors  Removing incentives for at-risk behaviors  Creating incentives for healthy behavior  Increasing situational awareness Normal Error Product of our current system design Manage through changes in:  Processes  Procedures  Training  Design  Environment

58. Ooppps!!!!!!