1. 1 Patient Safety 2013 Prevention of Medical Errors

2. 2 Why are we here? Concern over incidence of Medical Errors IOM Landmark Report (1999) –To Err is Human: Building a Safer Healthcare System –Statistics 44,000 – 98,000 Hospital deaths due to medical error

3. Impact of IOM Report Sparked a National Effort to: –change the culture of healthcare –change the systems of healthcare Culture change development: –Emphasis on compliance with standards –Good safety performance as a valued organizational goal –Emphasis on continuous improvement 3

4. Impact of IOM Report System Changes: Move from Blame to Safety –Shift from character and people related flaws to system and process flaws –Discard the need to blame –Embrace the blameless exploration of systems, processes and mechanisms 4

5. 5 Why are we here? To commit to paying greater attention to the problem We make a difference one at a time To evaluate current and new approaches To build better systems to reduce the incidence of error

6. 6 Why are we here? 2001 FL Legislative response –FS 456.013 –Mandates 2 hour course for ALL health care providers as part of licensure and renewal process Course shall include the study of: –root-cause analysis –error reduction –error prevention –patient safety

7. 7 Why are we here? FL BON Requirement –64B9-5.011 –Continuing Education on Prevention of Medical Errors

8. 8 FL BON Requirement Subject Areas: –Factors that impact the occurrence of medical errors –Recognizing error-prone situations –Processes to improve patient outcomes –Responsibilities for reporting –Safety needs of special populations –Public education

9. 9 Definitions Error (IOM): –The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim Adverse Event: –Injury caused by medical management rather than underlying disease condition

10. 10 Definitions Medical Error –Preventable adverse events with our current state of medical knowledge –Not defined as intentional act of wrongdoing –Not all rise to level of medical malpractice or negligence

11. 11 Reporting Requirements Florida Law requires all licensed facilities to: –Have Internal Risk Management and incident reporting system –Report Serious Adverse Events to: AHCA Agency for Health Care Administration See Sentinel Event Reported by year for guidelines

12. 12 Joint Commission National organization –Mission to improve the quality of care in healthcare institutions –Provides Accredited status to healthcare facilities

13. 13 Joint Commission Requires: –Process in place to recognize sentinel events –Credible root cause analysis (RCA) –Focus on systems not individuals –Risk reduction strategies –Internal corrective action plan Measure effectiveness of process System improvements to reduce risk

14. 14 Root Cause Analysis Goal-directed, systematic process uncovers basic factors that contribute to medical error Focuses primarily on systems and processes and not individuals Product of root cause analysis is an action plan to reduce risk of similar future events

15. 15 Root Cause Analysis Gather facts Assemble team Determine sequence of events Identify causal factors Select root causes Take corrective action and follow- up plan

16. Joint Commission Sentinel Event Statistics Joint Commission Website –Go to Topics, Sentinel Event, Statistics –View Sentinel Event Summary General Information – pg. 7 Root Causes – data unavailable – look at last year Trends Reported by Year 16

17. 17 Sentinel Events by Type Joint Commission Data 2004 - 2010 Top 6 –Wrong Pt., Wrong Site, Wrong Procedure –Delay In Treatment –Op/Post-Op Complications –Unintended Retention of Foreign Body –Suicide –Fall

18. 18 Sentinel Events by Setting Joint Commission Data 2004 - 2010 Hospital (63.9%) Psychiatric Hospital (11.4%) Emergency Dept. (6.8%) Psych unit in general hosp. (5.6%) Behavioral health facility (3.9%) Ambulatory Care (3.9%)

19. 19 Medication Errors Prevention Joint Commission abbreviations on the DO NOT USE list: What is the leading root cause of medication Errors?? Answer  Poor communication

20. Joint Commission Do Not Use List –U for Unit – write unit –IU for International Unit – write international unit –QD, QOD – Write daily or every other day –Trailing zero (X.0 mg.) – write (X mg.) –Lack of leading zero (.X mg) - write (0.X mg) –MS, MSO4, MgSO4 - write morphine sulfate, magnesium sulfate 20

21. 21 Items Reviewed annually by Joint Commission The symbols “>” and “<” All abbreviations for drug names Apothecary units The symbol “@” The abbreviation “cc” The abbreviation “μg”

22. ISMP: Tall Man Letters Table 1. FDA Approved List of Established Drug Names with Tall Man Letters acetoHEXAMIDE ­acetaZOLAMIDE hydrALAZINE – hydrOXYzine buPROPion ­busPIRone medroxyPROGESTERone methylPREDNISolone methylTESTOSTERone chlorproMAZINE – chlorproPAMIDE clomiPHENE – clomiPRAMINE cycloSPORINE – cycloSERINE niCARdipine – NIFEdipine DAUNOrubicin – DOXOrubicin predniSONE – prednisoLONE dimenhyDRINATE – diphenhydrAMINE sulfADIAZINE – sulfiSOXAZOLE DOBUTamine – DOPamine TOLAZamide – TOLBUTamide glipiZIDE – glyBURIDE vinBLAStine – vinCRIStine 22

23. ISMP Links to FDA Safety Alerts and Medication Safety Videos –http://www.ismp.orghttp://www.ismp.org –www.fda.gov/psnwww.fda.gov/psn And Much, Much More – A Great Resource! 23

24. Collaborative Learning Activity Work in small groups of 5 – 6 Discuss specifically what you can do in your life or practice setting to reduce medical errors Decide on 3 error reduction strategies to present to the group. 24

25. 25 Creating a Culture of Safety Understand human factors and system flaws Make safety everyone’s responsibility Report errors or near misses to decrease future error Actively seek improvement to process

26. 26 Creating a Culture of Safety 6 major categories of negligence: –Failure to follow standard of care –Failure to use equipment in proper, responsible manner –Failure to communicate –Failure to document properly –Failure to accurately assess and monitor –Failure to act as an advocate for the patient