Medical Error

Jeff Plant MD FRCPC

June 27, 2002

Outline Importance of the issue Why are we prone? Personal error Systemic error Dealing with error Where to go from here?

Medical Error Missed Salter 3 fracture

Sent home in post. slab as ?salter 1 #

Missed pyloric stenosis Sent home with anti-reflux measures

Missed volvulus Sent home as viral URTI

And so, the process begins…

What is Error? Error - the failure of a planned action to be

completed as intended or the use of a wrong plan to achieve a goal

Active error (sharp end) Occur at the level of the front-end and their effects

are felt almost immediately Latent error (blunt end)

Removed from the direct control of the operator

Why is this important? To Err is Human:Building a Safer Health

Care System “…when agreement has been reached to

pursue a course of medical treatment, patients should have the assurance that it will proceed correctly and safely so they have the best chance possible of achieving the desired outcome.”

Why is this important? Estimated that between 1-4% of

hospitalizations effected by error 5-20% of errors led to death Eighth leading cause of death in US

(more than MVC’s or AIDS)

Why is this important? Estimated that 40-60% of all diagnoses

wrong Effect on physician… Effect on patient/society…

What do patients expect? Witman et al, 1996 Arch Int Med

They want admission and, if necessary, apology for error

Half as likely to proceed with litigation if error admitted by physician

Why are we prone? Medical culture

Usually no mass casualties Socialized to view error as negligence Responsible for everything that happens to

your patient No admission of error The People’s Court…

Why are we prone? Emergency medicine

Living in a fishbowl Held to high standards Complex and tightly coupled system Time sensitive Multiple tasks ongoing

Medical Error - Personal Four steps of decision making

Data gathering Integration and processing of information Confirmation of diagnosis treatment

Data gathering New patient each

encounter Compressed time Too focused Inaccuracies of

physical exam Difficult setting

Integration and processing Voytovich et al

Lack of knowledge Premature closure Inadequate synthesis Omission

Premature closure highly prevalent and independent of level of training

Integration and processing Errors in cognition

Slips occur with errors in automatic tasks

Mistakes occur with errors in knowledge-based function

Physiologic and psychologic factors make these more likely

Confirmation of diagnosis Historical bias Inherent

strengths/weakness of test

Availability of test Cost of test

Treatment Medication errors Technical errors Pharmaceutical

company interests EBM = economic

based medicine

Medical Error - System Emergency departments are complex

and tightly coupled systems Complex

multiple interactions with other systems multiple feedback loops information often received indirectly

Medical Error - System Tightly coupled

Many time dependent processes arranged in sequences

No tolerance for delays in processes Sequences fixed

Medical Error - System Conditions that create error (DEPOSE)

Design Equipment Procedures Operators Supplies Environment

How do we cope? Most common coping mechanisms:

Denial of responsibility (blame the system) Discounting size of effect Emotional distancing

Less than half discuss errors with patients

1/3-1/2 discuss errors with colleagues

How should we cope? Accept responsibility for error Discuss with colleagues Disclose and apologize to patients Conduct an error analysis Make changes to reduce further errors Change medical culture locally and

nationally in dealing with error

New Look Systems rather than

people Nonpunitive approach Emphasize

multifactorial aspect Errors will occur Caregiver interactions Sharp and blunt end

Systems rather than people All errors are, in the end, a reflection of

the system Analysis of all components DEPOSE

Nonpunitive approach View errors as opportunity to improve

the system Training vs. punishment Encourage self-reporting to

colleague/committee

Emphasize multifactorial aspect Emergency dept is complex Errors rarely occur in isolation

Errors will occur Design systems with this in mind Develop buffers Ritualize behavior

Caregiver interactions Improve communication Formal signovers Computer documentation of patient

status and primary caregiver Clear expectations and roles of each

caregiver

Sharp and blunt end Focusing on front-line is most visible Blunt end tends to harbor latent errors Blunt end decisions drive sharp end

The Teams Approach MedTeams project extrapolation of aviation experience Identification of core team responsible

for patient 5 step approach

Teamwork approach Everyone’s opinion

respected -allowing for each individual’s expertise

Builds in certain degree of redundancy

Teamwork Each team

responsible for specific area

Color-coded http://team.drc.com Report cost savings

of $3-10 per patient

Conclusions Medical errors occur at a very high rate There are both personal and system

aspects of medical error Important to acknowledge error Go through intellectual exercise of

determining why error occurred See error as chance to improve system

Questions?