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Transcript of Medical errors
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Reducing medical error and increasing patient safety
Richard Smith
Editor, BMJ
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What I want to talk about
• A story• How common is error?
• Why does error happen?
• How should we think of error?
• How should we respond?
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A story
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How common is error?
• Harvard Medical Practice Study
• Reviewed medical charts of 30 121 patients admitted to 51 acute care hospitals in New York state in 1984
• In 3.7% an adverse event led to prolonged admission or produced disability at the time of discharge
• 69% of injuries were caused by errors
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How common is medical error?• Australian study• Investigators reviewed the medical records
of 14 179 admissions to 28 hospitals in New South Wales and South Australia in 1995.
• An adverse event occurred in 16.6% of admissions, resulting in permanent disability in 13.7% of patients and death in 4.9%
• 51% of adverse events were considered to have been preventable.
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How common is medical error?
• The differences between the US and Australian results may reflect different methods or different rates
• Other, smaller studies (including one from Britain) show similar orders of errors
• There are few studies from outpatients or primary care
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How common is medical error?
• An evaluation of complications associated with medications among patients at 11 primary care sites in Boston.
• Of 2258 patients who had had drugs prescribed, 18% reported having had a drug related complication, such as gastrointestinal symptoms, sleep disturbance, or fatigue in the previous year.
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Results of medical error• In Australia medical error results in
as many as 18 000 unnecessary deaths, and more than 50 000 patients become disabled each year.
• In the United States medical error results in at least 44 000 (and perhaps as many as 98 000) unnecessary deaths each year and 1 000 000 excess injuries.
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Types of error• About half of the adverse events
occurring among inpatients resulted from surgery.
• Next come–Complications from drug treatment
– therapeutic mishaps
– diagnostic errors were the most common non-operative events. In the Australian study cognitive errors, such as making an
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Types of error
• Cognitive errors--such as incorrect diagnosis or choosing the wrong medication-- more likely to have been preventable and more likely to result in permanent disability than technical errors.
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Which patients are most at risk?
• Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery
• Those with complex conditions
• Those in the emergency room
• Those looked after by inexperienced doctors
• Older patients
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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
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Why do errors happen?
• All humans make errors: indeed, “the ability to make mistakes” allows human beings to function
• Most of medicine is complex and uncertain
• Most errors result from “the system”--inadequate training, long hours, ampoules that look the same, lack of checks, etc
• Healthcare has not tried to make itself safe
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How to think of error?
• An individual failing
–Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis– It will not solve the problem--it will
probably in fact make it worse because it fails to address the problem
–Doctors will hide errors–May destroy many doctors inadvertently
(the second victim)
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How to think of error?
• A systems failure–This is the starting point for
redesigning the system and reducing error
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How to respond? Tactics
• Reduce complexity
• Optimise information processing
– checklists, reminders, protocols
• Automate wisely
• Use constraints
– for instance, with needle connections
• Mitigate the unwanted side effects of change
– with training, for example.
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Building a safe healthcare system (from James Reason)
• Principles• Policies
• Procedures
• Practices
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Building a safe healthcare system (from James Reason)
• Principles– Safety is everybody’s business
– Top management accepts setbacks and anticipates errors
– safety issues are considered regularly at the highest level
– Past events are reviewed and changes implemented
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Building a safe healthcare system (from James Reason)
• Principles
– After a mishap management concentrates on fixing the system not blaming the individual
– Understand that effective risk management depends on the collection, analysis, and dissemination of data
– Top management is proactive in improving safety--seeks out error traps, eliminates error producing factors, brainstorms new scenarios of failure
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Building a safe healthcare system (from James Reason)
• Policies– Safety related information has direct
access to the top
– Risk management is not an oubliette
– Meetings on safety are attended by staff from many levels and departments
– Messengers are rewarded not shot
– Top managers create a reporting culture and a just culture
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Building a safe healthcare system (from James Reason)
• Policies– Reporting includes qualified
indemnity, confidentiality, separation of data collection from disciplinary procedures
– Disciplinary systems agree the difference between acceptable and unacceptable behaviour and involve peers
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Building a safe healthcare system (from James Reason)
• Procedures– Training in the recognition and recovery of
errors
– Feedback on recurrent error patterns
– An awareness that procedures cannot cover all circumstances; on the spot training
– Protocols written with those doing the job
– Procedures must be intelligible, workable, available
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Building a safe healthcare system (from James Reason)
• Procedures
–Clinical supervisors train their charges in the mental as well as the technical skills necessary for safe and effective performance
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Building a safe healthcare system (from James Reason)
• Practices–Rapid, useful, and intelligible feedback on
lessons learnt and actions needed
– Bottom up information listened to and acted on
–And when mishaps occur• Acknowledge responsibility• Apologise• Convince patients and victims that lessons
learned will reduce chance of recurrence
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James Reason’s bottom line
• Fallibility is part of the human condition
• We can’t change the human condition
• We can change the conditions under which people work
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Conclusions
• Human beings will always make errors
• Errors are common in medicine, killing tens of thousands
• We begin to know something about the epidemiology of error, but we need to know much more
• Naming, blaming and shaming have no remedial value
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Conclusions
• We need to design health care systems that put safety first (First, do no harm)
• We know a lot about how to do that
• It’s a long, never ending job