Medication Errors and Patient Safety: Implementing

a Continuous Quality Assurance Program

Linda Allen, Gareth Buckley, Megan Eide, Sheri Holloway, Jude Kaufman, Chris

Sanchez, Dana Zimmel

Objectives

• Define patient safety reporting and the concept of just culture

• Differentiate between levels of patient harm • Identify common barriers to reporting • Explain structured ways that systems can be changed or implemented to reduce harm

Reasons for launching the Patient Quality and Safety Initiative

•  ONE HEALTH: In alignment with UF Health goal to “strive for the highest quality, safest experience for every patient.”

•  Creating a culture of patient safety is a key feature in the daily operations of human hospitals, and the UF Veterinary Hospitals has committed to do the same.

•  Quality and Safety are of critical importance to the UF Veterinary Hospitals.

IDInc

• Online database system used for managing patient safety reports

•  Access is from an icon on all Veterinary Hospital desktops

•  Helps manage, track and trend safety events •  Drives improvement

Quality and Patient Safety Journey

Mar 15 Initiated IDInc

Aug 16 AHRQ Survey

Nov 16 RCA – Order Writing

Mar 17 PQS team – rapid ID of anesthesia equipment issue

Sep 17 Hired Quality Officer

Today

• Core patient safety team • Linda Allen, Quality Officer • Dr. Gareth Buckley, Chief Medical Officer, SAH

• Dr. Megan Eide, Pharmacy Manager • Sheri Holloway, Assistant Director, SAH • Jude Kaufman, Assistant Director, LAH • Dr. Chris Sanchez, Chief Medical Officer, LAH

• Dr. Dana Zimmel, Associate Dean for Clinical Services

Culture of safety

• Everyone feels safe reporting patient adverse events

• Mistakes are approached in a fair and just manner, regardless of the severity of the outcome.

• Just Culture • Goals are designed to facilitate teamwork and improve communications

• Hierarchies are flattened • Everyone is encouraged to speak up

http://commission.org/topics/patient_safety.aspx

Reporting Algorythm

Who was harmed?

Who identified event?

Patient

Staff or Clinician

Client

Staff or Clinician

Go to IDInc and enter a PSR

*Complete Accident Investigation Report

(paper)

Go to IDInc and enter a Pt Complaint

What is a PSE/PSR?

• Patient Safety Event/ Patient Safety Report • Any event that caused actual or potential patient harm • Potential Harm may be:

• Near miss event • Require intervention to prevent harm

• Actual Harm may: • Require intervention •  Increased Hospital Stay •  Involve Major Harm: Death, Serious Safety Event

Question 1:

• What is a patient safety event?

Examples of PSEs – With Potential Harm

• Equipment not serviced at proper interval • Medication pulled for wrong patient but caught before

administration • Laboratory: Machine failed QC, so it was pulled

offline • Pharmacy: Caught label error prior to dispensing • Surgery: Instruments contaminated but caught

before use

Examples of PSEs – With Actual Harm

• ECC/PCW: Performed procedure on wrong dog • Anesthesia: Equine tibial fracture during recovery • Large Animal Hospital: Pump set incorrectly;

delivered lidocaine at wrong rate, horse became ataxic

• Laboratory: Incorrect test results were reported to DVM

• Pharmacy: Medication Labeled with incorrect formulation

• Surgery: Performed surgery on the wrong limb

Event Reported

Initial Review (Quality officer)

Management Investigation (Technician Manager or

Service Chief)

PQS team for further investigation

Event Reviewed and Closed

(Medical Director)

Major patient harm or repetitive event

Routine event

Management investigations

• Initially by area manager • Can re-assign if needed • Review medical record • Talk to individuals involved • Goal is to determine what happened

• Was there an error or not? • If error, how can we prevent it?

• Identify and manage system imperfection

Root cause analyses

• Comprehensive, systematic method to identify gaps in hospital systems

• Develop actions to reduce risk of sentinel events • What happened? • Why did it happen? • What can be done to prevent reoccurrence?

• Focus on systems, processes – NOT people

http://commission.org/topics/patient_safety.aspx

Hierarchy of intervention effectiveness

http://patientsafe.wordpress.com/

How do we use the information? !  Tracking and Trending such as

" The types of reports by department " The annual number of patient harm events by month " Tabulated medication errors by medication " Scholarly initiatives for residents and staff

!  Identifying common problems across the organization such as "  Treatments to the wrong patient due to same name "  Missing forms or checklists "  Most frequent medication errors "  Equipment maintenance log completions

!  Making improvements such as "  Improving protocols per evidence based research "  Creating checklists "  Moving similar drugs to different storage locations in drawers

http://www.qualityindicatorys.ahrq.gov/

Just Culture

• An approach to medical error reporting that emphasizes learning and accountability over blame and punishment

• Basic knowledge • Everyone makes mistakes • Choice to follow the rules • Mistakes highlight opportunity

• Responsibility •  Leaders set safety rules and make it possible to follow • Employees must follow safety rules and report safety events

http://psnet.ahrq.gov/ http://justculture.org/

Just Culture Punishing people for making mistakes generates fear of retaliation.

 When employees are afraid to report errors and do not report, managers no longer learn about safety issues that need to be fixed before they happen.

 Teaches managers/supervisors to evaluate what led to each event   1. Understand why the mistake occurred   2. Identify opportunities for improvement   3. Work with the employee

http://psnet.ahrq.gov/

Question 2:

• Describe the most important elements of a Just Culture approach to mistakes.

The three behaviors that fuel errors • Human error —accidentally doing something

unintended due to forgetfulness or a mistake • At-risk behavior —taking risks and not following

rules due to confidence an error will not result • Reckless behavior —taking risks known to be wrong

due to disregard and unconcern for potential harm

http://psnet.ahrq.gov/ http://www.ismp.org/ http://justculture.org/

Human Error: Unintentional; slip, lapse or mistake

Contributing factors: • Fatigue, lack of sleep, illness • Mental distractions, fear, worry, stress • Environmental distractions, noise, disruptions, clutter,

lighting • Too many hand-offs increasing the risk of

miscommunications

Managing Human Error

• Console employee •  Empathize and listen •  Recognize that we are all human and anyone could

have made the same mistake

Cause Human Error

Action Console

http://justculture.org/

At-risk Behavior: Taking risks; “Drift”

Contributing Factors: • Time pressures, sense of urgency • Multi-tasking • Drift away from standard processes and

redundancies because no negative consequences • Overconfident and take short-cuts • Watch others not following the rules with no bad

outcome

http://justculture.org/

Managing At-risk Behavior

• Coach the employees • Remind of risks • Coach whether or not there is any harm • Often practiced by more than one employee • Explain consequences for repeated behavior

Cause At-risk

Behavior

Action Coach

http://justculture.org/

Reckless behavior: Conscious disregard of rules

•  Rare •  Employee deliberately marginalizes patient

safety •  Repeated at-risk behavior •  Requires disciplinary action whether or not it

results in any harm

Cause Reckless Behavior

Action Disciplinary

Action

http://justculture.org/

Building a Culture of Safety

1. When employees trust that they can report a mistake without fear of punishment, and that their reports will be investigated and result in system improvements, they begin to trust more and report more of the safety conditions they see

2. As hospital leaders act on more safety reports, hospital systems improve and serious harm is avoided

3. In order for employees to trust their leaders, the hospital must have a fair and consistent way of managing errors

Question 3:

• What are barriers to reporting patient safety events?

Patient Safety in 2017-2018

Creating a Safety Culture

10.81 9.09

0

5

10

15

20

2016 2017 Rat

e pe

r 10,

000

Pat

ient

Vi

sits

Serious Safety Events (Harm F+) Harm

3.74

16.64

25.20

0 5

10 15 20 25 30

2015 2016 2017 Rat

e P

er 1

000

Pt V

isits

Overall Patient Safety Reporting Rate Per 1000 Patient Visits

Reporting

What we are learning?

0 2 4 6 8 10

Express Report Patient Actions

Skin/Eye/Wound Integrity Infections

Equipment/Supplies Lines, Drains, Airways - LDAs

Other Surgical/Invasive Procedure

Pharmacy Variances Laboratory Variances

Medication Procedure Variances

Event Rate Per 1000 Patient Visits 2017

943 PSRs

Medication Variances 0 10 20 30 40 50 60 70

Improper Dose

Wrong drug/IV fluid

Missed/omitted dose

Wrong time

Other

Wrong patient

Wrong administration route

Medication Obtained, Not Used

Labeling/Documentation error

Order Variance

No Harm Moderate Harm Harm

Improvements from PSRs

•  Early Sepsis Recognition and Treatment

•  Standardized medication order writing

•  Implemented a checklist for Anesthesia equipment maintenance

•  Improved surgical checklist

Improved Surgical Checklist

Services Impacted by 26 Improvements

Anesthesiology

ECC Gville

ICU

Imaging

Lab: Aquatic Pathology

Lab: Central Receiving

Lab: Clinical Microbiology

LAH

Large Animal Surgery

Medical Oncology

Pharmacy

Progressive Care Ward

SAH Surgery Ortho

Small Animal Internal Medicine

Zoo and Wildlife Medicine