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Week 8 - Adverse Effects and Error Reporting.pdf

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NSE 407
N S E407

Week 8 - Adverse Effects and Error Reporting December-06-12 11:26 AM Lecture Notes • 3 most commonareas - surgery, medication, and infection. • 1 out of 13 adult patients admitted to a Canadian hospital encounter an adverse event. • 1 out of 9 adults will potentially be given the wrong medicationor wrong medication dosage. • Between 9,000and 24,000patients die per year due to adverse events. • 37% of adverse events are ‘highly’ preventable. • 24% of preventable adverse events are related to medication error. Outcomes • 1.1 million added days in hospital and $750 million in extra healthcare spending • 185,000adverse events per 2.5 million hospital admissions in Canada per year of which close to 70,000are preventable • More Canadians die due adverse events in hospitals than from breast cancer, motor vehicle accidents or AIDS • Increasing technology = more errors • Most errors do not result in harm (latent error) • Many serious errors preceded by near misses • Errors of omission (neglecting to do something) are most common • Many errors are preventable Lucian Leape - “grandfather” of medical error, other quotes: 1. The vast majorityof errors in medicine (and elsewhere)are NOT due to laziness, inattention, or incompetence 2. Blaming the individual who made the error is punishment, blaming the system that allowed the error to occur is the beginning of improvement. Basic tenets of human error • Human performance is imperfect (just ask your kids), it’s how we handle mistakesthat defines the quality of our work. • The commitmentof errors is (with rare exceptions)unintentional, and usually unconscious. Otherwise they are caught before they occur. • Any system that assumes human perfection (i.e., does not accommodatefor variations or discrepancies) forces errors to occur…and to go unchecked. (consider aviation) Person Vs. Systems Approach Person System •Errors are the result of human failures •Begin with the premise that anything can and •Humans generally perform flawlessly will go wrong •Perfect performanceis the expectation •Don’t expect humans to perform perfectly •Use retraining and punishment to root out •Design systemsaccordingly in a proactive way “bad apples” •Collective preoccupation with possibility of failure Reactive Vs. Proactive Approach • Reactive:blame individual, punish individual • Proactive:learn from mistake and moveon Perceived Barriers to Medical Error Reporting: An Exploratory Investigation - Uribe et al (2002) • The purpose of this study was to collect survey data on perceptions regarding barriers to reporting errors and the potential for those barriers to be modified. • Medical errors are largely underreported across healthcare institutions. This problem can be attributed to different factors and barriers present at organizational and individual levels that ultimately prevent individuals from generating the report. • Study explored the factors that affect medical error reporting among physicians and nurses at a large academic medical center. large academic medical center. Introduction • The report found preventable adverse events to be a leading cause of death in the US and estimated medical errors in the US hospitals result in at least 44,000and as many as 90,000deaths per year. • One of the greatest impedimentsto error-reductionefforts in health care delivery organizations is the lack of data on the occurrence of errors. • Despite their high incidence, medical errors are largely underreported across healthcare organizations and institutions. Medical-Error Reporting • An error is defined as "the failure of a planned actions to be carried out as it is intended (i.e. an error of execution) or the use of a wrong plan to achieve an aim (i.e. an error of planning). • Not all errors result in an adverse event • Medical errors that do not result in a negative outcomeare near misses. • Adverse events that have occurred as a result of a medical error are known as preventable adverse events. • The occurrence of any medical error is influenced by various factors present at the organization and/or the individual level. • Organizational factors include, but are not limited to: • Workload • Staffing levels • Job design • Established policies and procedures • Individual factors include: • Motivation • Health • Negligence • Some factors such as culture and education can be characterized as both organizational and individual. • Once an error has occurred, the error managementsteps that follow are: 1. Error recognition and correctionof the error or 2. Minimization of its effects. • If the error is not recognized, the correctivefactors cannot take place. • The error managementphase, which is reactive in nature, determines whether an error results in a near miss or an adverse event. • In contrast, the post-error managementacts of error reporting and followup activities,such as the root cause analysis, to identify process improvementsand other strategic measures that can prevent future errors. • The amount of underreporting of adverse events is estimated to range from 50% to 96% annually. • Minor adverse events and near misses are the least reported, given the nature of the outcomes. • Underreporting of errors can be attributed to various factors present at the organizational and individual levels that ultimately prevent individuals from generating a formal report. • Certain factors that prevent error reporting are specific to healthcare professionals. • Compared to pilots, physicians are particularly reluctant to discuss error and to question those higher in the organizational hierarchy. • Reporting of errors in the medical setting usually take place in an informal, nonofficial manner among the healthcare professionals involved with patient care. • Clinicians are expected to documentcomplicationsand adverse events in the medical record. • Without formal, written reports containing thorough documentationof error incidents, patient safety opportunities are severely limited. Results • Two additional factors, fear of lawsuits and hesitancy regarding "telling" on somebodyelse reflect in part the cultural issues in the medical and nursing professions as well as the litigious nature of American society. • Factors that appeared to be the most modifiable involve mainly the structures and processes for medical error reporting (organizational level factors) and educational issues. • Factors that appeared to be less likely to be modified involve mainly cultural issues (i.e. fear of lawsuits, fear of being blamed, etc.) and motivationalissues. lawsuits, fear of being blamed, etc.) and motivationalissues. • The exploration of the differences between physicians and nurses suggests that physicians perceive more factors as barriers than nurses. • Nurses' top six barriers for medical error reporting: 1. Time involved in documenting an error 2. Not being able to report anonymously 3. Extra work involved in reporting 4. Hesitancy to "tell" on somebodyelse 5. Thinking that it is unnecessary to report the error because it had no negative outcome 6. Fear of lawsuits Discussion • By identifying the most significant barriers to reporting and the most modifiable barriers, this study helps prioritize management actions. • Improvementsin medical error reporting can be attained by addressing these issues promptly and by redesigning some of the reporting mechanismsto facilitate and improve the medical error- reporting process. • Educational efforts should be made to make the professionals aware of the importance and value of the reports and to demonstratehow their contribution in reporting is a key componentof efforts to improvequality and enhance patient safety. • Long-termstrategy factors involve cultural issues that will require a longer period of time to be modified. • Even though the lack of interest and motivationfor reporting occurs mainly at the individual level, it can be largely influenced by education and promotionalactivities conducted by the organization. • Educational weaknessescan be solved by providing appropriate information to professionalsabout the error-reporting mechanismsand by implementing sometargeted training to increase
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