Hussam Sakkijha, M.D, FCCP, FACP Diplomat, ABSM - RM Solutions

Safety in The ICU
Hussam Sakkijha, M.D, FCCP, FACP
Diplomat, ABSM

Health Care Should Be…
Safe
Timely
Effective
Efficient
Equitable
Patient-Centered

Are we safe??!!

New York Times, Science Tuesday
February 17, 2004

Statistics
• Healthcare costs (2004) are approximately
$1.6 trillion
• Cost of medical errors: $80 billion
• Approximately 48,000 - 98,000 patients
die/yearly due to medical errors (IOM 2000)
• Recent study suggested deaths are higher, up
to almost 300,000 annually (Health Grades
Inc., 2004)

• CDC lists medical errors as the 6 th leading
cause of death, ahead of diabetes,
pneumonia, Alzheimer’s, and renal failure
• Preventable healthcare-related injuries cost
our economy $17 to $29 billion annually, half
of which are added healthcare costs
• 10% due to human factors
• 90% due to healthcare system design
• 80% of medical errors are preventable!

How Dangerous is Health Care?
Less than one death per 100,000 encounters
Nuclear power
European railroads
Scheduled airlines
One death in less than 100,000 but more than 1000 encounters
Driving
Chemical manufacturing
More than one death per 1000 encounters
Bungee jumping
Mountain climbing
Health care

• The issue of patient safety gained
medical and public consciousness
after the publication of the IOM
report on safety in the fall of
1999.

Error is Inevitable Because of Human
Limitations
• Limited memory capacity – 5-7 pieces of
information in short term memory
• Negative effects of stress – error rates
• Tunnel vision
• Negative influence of fatigue and other
physiological factors
• Cognitive performance after 24 hrs. without sleep
equivalent to blood alcohol of .10 !
Dawson et al, Nature, 1997
• Limited ability to multitask – cell phones and
driving

“…….inherent limitation of human
memory, effects of stress and
fatigue, the risks associated with
distraction and interruptions and
limited ability to multitask ENSURE
that even skilled, experienced
providers WILL make mistakes.”
Leonard M, et al Qual Saf Health Care 2004;13
(supp 1):i85-i90

Rather than being the main instigators of an
accident, operators tend to be the inheritors of
system defects….. Their part is that of adding
the final garnish to a lethal brew that has
been long in the cooking.”
James Reason, Human Error, 1990

Fallible Defenses
(Or “The Swiss Cheese Model” of Safety)
Some holes due
to active failures
Operative/Post-Op Complications
Events Relating to Medication Errors
Deaths of Patients in Restraints
Hazards
Inpatient Suicides
Transfusion Related Events
Correct Tube-Correct Connector-Correct
Hole
Patient Falls
Deaths Related to Surgery at Wrong Site
Harm
Other holes due to
latent conditions
Errors in the design, organization, training or
maintenance that lead to operator errors and whose
effects typically lie dormant in the system for lengthy
periods of time.
12

Safety Measures
• How often do we harm patients?
– BSI and VAP
• How often do we do what we should?
– Vent bundle sepsis bundle
• How often do we learn from defects?
– Learn from one per month
• How well do we improve culture?

المرضى عرضة للسقوط

CASE

72 years old WWII male veteran
who is known to have mild
COPD,Quit smoking 30 years ago,
BPH and colon polyps who
presented to outpatient GI lab for
screening colonoscopy, patient
denied any complaints at the time
and he was in an excellent
functional state.

He was prepared for the procedure.
During the procedure he was given
total of 10 mgs of Versed and 100
mgs of Demerol.
Started to develop hypoventilation
requiring mechanical ventilatory
support.
Was transferred to MICU.
The procedure was not completed.

He remained intubated overnight.
Underwent colonoscopy next
morning which was normal.
Successfully weaned off the
respirator and was extubated.
Transferred to medical flour for 24
hr observation.

Later that night, a code blue was called
on the patient who was unresponsive,
hypotensive and bradycardic.
CPR was initiated.
We learned from the nurse that patient
–mistakenly- was given 100 mgs of
metoprolol, 20 mgs of lisinopril and
180 mgs of verapamil which was
supposed to be given to his room
mate who had severe uncontrolled
hypertension.

Our patient has no history of
hypertension and his average
blood pressure during current
hospitalization was 110/50.

Patient was given Ca, Glucagon and
fluids.
Continued CPR.
Continued to be bradycardic
unresponsive to atropine or
cutaneous pacing.
Developed a systole.
CP Resussitative measures failed and
the patient died.

ADR
• >10% of hospital admissions are secondary
to ADR.
• Substantial number of ICU admissions are
due to ADR.
• The average ICU patient receive 8-12
different medications daily.
• The incidence of ADR increase in
proportion of the total No. of medications
used.

• ICU is a fertile environment for
pharmaceutical misadventures.
• Up to 30% of hospitalized patients
experience ADR before discharge
regardless of the severity and
consequences of these reactions.

• The overall incidence of serious ADR
is 6.7%.
• The incidence of fatal ADR is 0.32%,
76% of which were dose dependent
and consequently preventable.24%
were idiosyncratic or allergic in
nature.

• Drug errors are 7 times more
likely to occur in the ICU than
the general wards.
• The rate of ADR is highest in
MICU at 19.4/1000 patient days
as compared to 10.6/1000
patient days in general medical
wards.
• Incidence remain higher even
with correction for the No. of
administered drugs.

ICU Risk Factors for Committing Medication Errors
Patient
ICU environment
• Complex environment
• Emergency admissions
• Multiple care providers
ICU
Environment
Patient
• Severity of illness
• Extreme of ages
• Prolonged hospitalization
• Sedation
Medications
Medications
• Types of medications
• Number of medications
• Number of interventions

Significance of ADE
• 1% of ADE are fatal.
• 42% of ADE are serious or life
threatening.
• 57% of ADE are significant.

Multiple stages of drug delivery:
prescription(49%)
transcription(11%)
dispensing (14%)
administration(26%)
monitoring.
Errors occur at all stages.

Context in which errors occur
• High No. of admissions.
• Busy unit.
• Time 12:00-16:00 .
“because of the total No. of prescriptions”
• Understaffing.
• Overworked, exhausted, fatigued
excessively stressed staff.

To err is human ….
But errors can be prevented.

What Type of Human Glitches Cause
Harm?
JCAHO Sentinel Event Statistics, 2004

JCAHO Sentinel Event Statistics, 2004

Things to do
Improve communication
amongst health care providers.
Appropriate staffing with
experienced and
knowledgeable staff.
Identify and report errors and
safety concerns.

Assumptions
Fatigue
Distractions

Safety- background
• The National Patient Safety Goals
(NPSGs) were established in 2002 to
help accredited organizations address
specific areas of concern in regards to
patient safety
• The NPSGs underwent an extensive
review process in 2009 resulting in
revised 2010 NPSGs
• No new NPSGs were developed for
2010

2011 International Patient Safety Goals
or Quality Initiatives ( QI)
• QI 1- Improve the Accuracy of Patient Identification
• QI 2- Improve Effective Communication Amongst
Caregivers
• QI 3- Improve the Safety of Medication Administration
• QI 4- Reduce the Risk of Health Care Associated
Infections
• QI 5- Reduce the Risk of Patient Harm Resulting from Falls
• QI 6- Encourage Patient Involvement in their Care
• QI 7- Identify Patients that are at Risk for Suicide
• QI 8- Recognize and Respond to a Change in the Patient’s
Condition ( MEWS)
• QI 9- Universal Protocol- Implement a “Time Out” Prior to the Initiation of any
Procedure
41

Patient identification
Recommendations
• Encourage the use of 2 identifiers (e.g. name and
date of birth)
• Identify the patient before care is administered
• Standardize the identification process
• Provide a clear policy and procedure for identifying
the patient
• Policy support through resource availability

Recommendations (cont.)
• Appropriate education and training
• Provide a clear protocol for identifying patients who
lack identification
• Encourage patient participation
• Labeling of specimens in the presence of the patient
• Monitoring compliance

Fall Prevention
Priorities
Fall Risk Assessment
Proactive Interventions
Patient/Caregiver Education
Evaluation

Kingdom of Saudi Arabia
Ministry of Health
King Fahad Medical City
Nursing Department
FALL RISK ASSESSMENT
Instructions: Each adult patient is to be assessed as to their risk of falling at time of
admission, transfer in, return from operating theatres and/or whenever condition changes.
Nursing actions are to be taken depending on the total risk score and recorded below.
On discharge patient/family teaching to be given as appropriate.
RISK FACTORS CRITERIA POINTS
PATIENTS SCORE
History of falls
Two or more
Diagnosis
(co-morbidity)
Ambulation aid
IV/Saline lock
Gait/Transferring
Mental status
Medications
Yes
No
Yes
No
Furniture/rails/walls
Crutches/Walker/Cane
None/Bedrest/Wheelchair/Nurse
Yes
No
Impaired
Weak
Normal/Bed rest/Immobile
Forgets limitations
Oriented to own ability
On 4 or more prescription drugs
Anti Hypertensive, Narcotics, Sedatives,
Diuretics, Laxatives, Analgesics, etc
TOTAL SCORE
NURSE INITIALS AND EMPLOYEE NUMBER
Additional observations/comments relevant in assessing risk:
………………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………..
المملكة العربية السعودية
وزارة الصحة
مدينة الملك فهد الطبية
25
0
15
0
30
15
0
20
0
20
10
0
15
0
5
10
Medical Record No:
Patient ID
Name:
Specialist:
Hospital: Unit: Room/Bed:
Gender:
Age in years:
Date of Admission:
Time:
Date Date Date Date Date Date Date
:

RISK SCORE 50 and above 28 - 49 0 - 27
RISK ASSESSMENT
High
Check Every Shift or in any change
of Patient status
Moderate
Check every 5 days or in any change of Patient status
Complete Fall Risk Assessment Action Plan, add to patients Care
Plan (see over)
Low
Change in Patient
status
PREVENTATIVE ACTIONS AND INTERVENTIONS: (Tick in the box if that action taken)
Tick Environment Tick Nursing Tick Multidisciplinary Tick Patient centered
Good lighting
Orientate patient to
surrounding
Medication review
Compliance with advice from
the disciplinary team
Non slip floors
Move room closer to nursing
station
Individualized equipment/aid
specific to patient need
Involve family and patient in fall
prevention program
Level flooring
Clear identification e.g.
colored arm band
Minimize distraction
Check patient wearing
appropriate clothing and shoes
Remove clutter
Use patient alarms
(if available)
Exercise program
Use adjustable high/low bed
Supervision when mobilizing
Reference: Morse, J. M. (1997). Preventing Patient Falls. Thousand Oaks: Sage.
Reference: Nursing Department IPP Falls Prevention

What is FOCUS – PDCA?
• A simple methodology to apply to
problem solving
• It is a hospital wide process
– Consistency and organization
– Documentation
• It is NOT just a storyboard!

DO
FOCUS- PDCA
The second part of the cycle
PDCA
PLAN
ACT
CHECK

Teams and Technology…
Hi-tech band-aids don’t replace teams
50

Building Communities of
Competence for Workplace Safety
‣ Safety as a way of thinking and acting
wherever you are (work, home, leisure)
‣ Everyone is responsible for safety
‣ Everyone should feel comfortable to
report a safety issue
‣ Everyone should be encourage to report
‣ Safety should be part of organizational
culture and investment in human capital