evaluation form to receive a certificate of completion

ICTS Brown Bag Seminar
• Successful Completion: Participants must complete an
evaluation form to receive a certificate of completion
• Contact Hours: 1 contact hours is available to those
who meet the successful completion requirements
• Sponsorship & Commercial Support: This activity has
received no sponsorship or commercial support
• Conflict of Interest: No conflicts of interest were
identified
• Non-Endorsement: Accreditation approval refers only to
MONAs continuing education activities and does not
imply MONA or ANCC Commission on Accreditation
endorsement of any commercial products
• Off Label Use: There will be no discussion of uses of
products other than what is approved by the FDA.
• Expiration: Contact Hours expire on November 17, 2013
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• Principles of Patient Safety—An Overview
• Reporting of Events
• Demonstration of WUSM ERS
Research Coordinators August 2012
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Definition
Patient Safety
- Absence of preventable harm: avoidance of errors
in clinical care resulting in injury to our patients
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Harm—Scope of the Problem
•More than 1 million preventable adverse
events occur in the US each year
•An estimated 44,000-98,000 people die in
hospitals each year from preventable
medical errors
Institute of Medicine. 1999. To Err is Human: Building a safer health system.
Many mark the release of To Err is Human by the Institute of Medicine as the first major
study in patient safety and an attempt to offer ideas on what can be done in prevention.
The IOM took the Harvard study and extrapolated its findings to create the often quoted
“44,000 – 98,000” statistic.
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2

Yearly Attributable Deaths
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
MVA Breast Cancer AIDS Medical Errors
Even using the lower number from the IOM study, Medical Errors killed more
Americans than car accidents and breast cancer. There is no indication that
the annual rate of deaths from errors decreased since 1999.
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AHRQ 2001
High Profile Deaths from Medical Errors
Chemotherapy overdose
Betsy Lehman, 39
Dana Farber
ABO compatibility
checking error-- transplant
Dehydration and oversedation
Growth hormone
overdose
Josie King, 18 months
Johns Hopkins
Jesica Santillan, 17
Duke
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Sebastien Ferrero, 3
U. Florida
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Traditional Approach to Error
Personal responsibility and theory of “bad
apples"
• Error is a character flaw
• Focus on the incident and the individual
• Punishment and Remediation
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Patient Safety Approach to Error
• Humans make mistakes, even if we’re careful and well-intentioned. The
goal of Patient Safety is not to eliminate human error, but to create safe
systems to prevent them from reaching the patient.
• Ask “How did it happen” not “Who did it’?
• Systems or processes that depend on perfect human performance are
fatally flawed.
• Most adverse events result from a cascade of failures in a flawed
system
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4

Pioneers in Patient Safety
“We can’t change
the human
condition, but
we can change
the conditions
under which
humans work.”
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James Reasons’ “Swiss cheese” Model
Some holes due
to active failures
Hazards
Harm
Other holes due to
latent system factors
Successive layers of defenses, barriers, & safeguards
• No single individual error (active error) is sufficient to cause an accident
• The majority of medical errors are caused by faulty systems, processes and
conditions that lead people to make mistakes or fail to prevent them
• Latent conditions = system faults that increase the probability of individuals making
errors
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5

Why has it taken so long to make things safer?
• We don’t treat the delivery of healthcare as a science
• Most errors don’t harm patients/failure to capture and learn
-“no harm, no foul” usually brings a sigh of relief, not action
• Need to overcome the culture of medicine which expects
perfection instead of expecting error and planning for it
-get away from the idea that your own effort drives everything
-healthcare is a team sport: overwhelming evidence that diverse input
improves outcomes
• Some of us still believe smart people, working hard, will not
make mistakes
• We map the human genome and transplant hearts and lungs,
but we don’t wash our hands
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Human Factors
Examines activity by way of component tasks and
considers it in terms of:
Physical demands: fatigue, illness, substance abuse, stress
Skill requirements: inexperience, fear, procedural shortcuts
Mental workload: boredom, cognitive shortcuts, reliance on memory
Team dynamics: stress, shift work
Device design: equipment/programs
Environment:
fixed: lighting, heat, unnatural workflow space
controllable: noise, interruptions, motion, clutter
We know errors result when these factors are violated
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6

Human Factors Principles
• Avoid reliance on memory—seven digits is our max
• Decrease reliance on vigilance
• Increase verbal feedback/structured communication
• Standardize what you can, and only that; use
protocols & checklists wisely
• Use constraints and forcing functions to create a
safety net to save you from yourself
• Reduce handoffs and standardize content
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When the posted speed limit is 65mph, how fast do you drive? What impacts your speed?
•Time of day?
•Whether it’s a speed trap?
•Are you late picking up kids from daycare?
•Is the weather bad?
Even the best intentioned are pressed to step over known safety precautions in medicine, resulting
in “practice creep”.
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7

• Report
How Do We Respond to Errors?
—Report and Learn
• Track and trend to learn
• Devise strategies to build a better safety net to
prevent future events
• Talk to each other openly and remember the
substitution test
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Traditional Voluntary Reporting in Hospitals
Lost Opportunities to Learn from Physicians
• Key Findings:
Hospital staff did not report 86% of events to incident reporting systems
Physician accounted for less than 2% of reports
Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. January
2012 OEI-06-09-00091
• Low physician reporting is problematic because it hinders the ability to
identify and mitigate risks. Physicians view health care through a unique
lens, which allows them to identify certain types of hazards and certain
contributing factors better than others.
Noble, DJ, Pronovost, Underreporting of Patient Safety Incidents Reduces Health
Care’s Ability to Quantify and Accurately Measure Harm Reduction P. J Patient Saf 2010; 6:24
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8

How to Build a Healthy Reporting Culture
You Have to Start Somewhere/Anywhere
□Teamwork
□Open p communication
□Management Support
No blame but
accountability
Co-workers save others from
learning first- hand errors
Safety
Culture
Willing and able to report
Observations are
welcome and
solicited
Clinical changes visible
and feedback frequent
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What to Report?
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9

Most Common Ambulatory Events
Which May Result in Harm
•Failure to inform patient of clinically significant test result
•Wrong test ordered or test not ordered when appropriate (ex: no HIV testing
prenatally)
•Wrong medication, wrong dose ordered, or medication not ordered when appropriate
•Failure to monitor high risk medication (ex: Warfarin/INR; Insulin)
•Failure to notice dispensing errors (medication reconciliation not done)
•Wrong treatment ordered
•Tests ordered but not done
•Errors arising during the performance of a clinical task
•Wrong, delayed or missed diagnosis
•Wrong treatment decision
•Scheduling the wrong surgery or wrong site surgery
•Errors in communication between physicians, services
•Failure to respond to a consultation or communicate with referring physician
resulting in delay or harm
•Failure to schedule a test when requested by another service
•Failure to monitor tests ordered but not scheduled by patient
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Siteman East Chemotherapy Infusion Map
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10

OB Triggers
‣ Maternal Mortality
‣ Maternal cardiopulmonary arrest
‣ Excessive maternal blood loss (roughly >1500cc)
‣ Stillbirth of a baby admitted alive (excluding extreme prematurity or lethal anomalies)
‣ Cord pH

When you learn of an event
• Report it in the system at http://ers.wusm.wustl.edu
• If the event is serious and harmed the patient, notify
WUSM Risk Management at 362-6956, as you usually
• Refer to WUSM ERS Guidelines for more information
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The type of thinking that got us into these problems
will not be the type of thinking that will get us out.
Albert Einstein
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Accessing the WUSM Event Reporting System
Open Internet Explorer and navigate to:
http://ers.wusm.wustl.edu
• Your domain will create a shortcut on your desktop or save the link to
your favorites.
• If you are signed on to the secure WUSM computer network, you
should not be prompted for your username and password.
• WUSM ERS is optimized for Internet Explorer, Version 7.0 and above.
Other web browsers, such as Firefox, Google Chrome, and Safari,
can be used to enter events, but functionality is limited.
• If you are not on the secure WUSM computer network, use Citrix or a
Virtual Private Network (VPN) connection to access ERS.
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Discussion
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