You are Yale New Haven: Safety, Errors and You - PowerPoint Presentation

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You are Yale New Haven:Safety, Errors and You

Robert L

Fogerty

, MD, MPH

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Outline

Scope of the problem

Macro level

Micro level

Yale New Haven data

When errors occur

Disclosure and reporting

Root cause analysis

Swiss Cheese model

Corrective actions

Pronovost

&

Semmelweis

Special Guest

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Scope of ProblemTo Err is Human: Building a Safer Health System (IOM, 1999).

44,000-98,000 people die each year from preventable medical errors.

71,000 deaths from Diabetes (2007 CDC)

74,000 deaths from Alzheimer’s (2007 CDC)

35,000 deaths from Septicemia (2007 CDC)

If included on death certificates, medical errors would rank in top 10, as high as sixth.

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Scope of ProblemErr

Medical Errors costs in US: $17 - $29Billion / year

Workplace deaths: 6000/year. Medication error deaths: 7,000/year

More people die from Medical Errors than:

Breast Cancer (41,000) (2007 CDC)

Emphysema (13,000) (2007 CDC)

Kidney Diseases (46,000) (2007 CDC)

Homicide, Birth Defects, Asthma, Cervical Cancer, HIV COMBINED (approx. 46,000 total)

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Example of Medical Error

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Scope of Problem (cont.)2007: Wrong side brain surgery – three times.

Brown

2003: Heart/Lung transplant, incompatible blood types (Donor A, Recipient O).

Duke

2006: Patient paralyzed but not anesthetized for exploratory laparotomy. Alert and oriented for first 16 minutes of surgery.

Patient committed suicide two weeks later

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Gossypiboma

Retained sponge/towel following surgery

Yes, it has an actual, formal name

And an ICD-9 code (998.4)

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Outline (cont.)

Scope of the problem

Macro level

Micro level

Yale New Haven data

When errors occur

Disclosure and reporting

Root cause analysis

Swiss Cheese model

Corrective actions

Pronovost

&

Semmelweis

Special Guest

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US Department of Health and Human Services,

http://www.hospitalcompare.hhs.gov/

. Accessed Jan 12, 2012.

But, I am Yale New Haven

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Yale New Haven Errors6 year old patient here for elective hernia repair.

Wrong side surgery

LP performed, samples not labeled.

Need to repeat procedure

Wrong side chest tube.

Wrong side

thoracentesis

.

Retained surgical sponge/instruments.

3-4 times annually.

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Outline (cont.)

Scope of the problem

Macro level

Micro level

Yale New Haven data

When errors occur

Disclosure and reporting

Root cause analysis

Swiss Cheese model

Corrective actions

Pronovost

&

Semmelweis

Special Guest

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When Errors Occur

Foolish, arrogant and dangerous to believe you will never commit an error.

You have an ethical and professional DUTY to recognize the error.

Personal improvement

Prevention of repeating error

Others can learn

Disclose, Disclose, Disclose.

Mandated by Joint Commission.

AMA guidelines.

Endorsed by Legal and Risk Services here at YNHH

688-2291

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When Errors Occur (cont.)Rosner

et al (Arch

Int

Med, 2000)

“Medical errors occur and are sometimes unavoidable. Physicians generally, but not always, have ethical and moral obligations to disclose their errors to the patient. Because common medical errors can be expected, physicians are obligated to work within health systems toward reducing systems flaws that promote errors. However, the obligations of physicians to disclose errors made by others are less clear.”

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Root Cause AnalysisStructured investigation into events.

Goal is to define the origin of the event.

No single methodology.

Multiple viewpoints (interdisciplinary)

Thorough

Repeated

Establish a sequence of events

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Making a Diagnosis

Very similar process to a RCA

Patient with a fever

Dx

: Fever

What causes fever?

IL-1

Innate Immune System stimulation

Infection

Leukemia/lymphoma

Clot

Exposure

Drugs

More background needed.

History, physical, laboratory assessment, radiographic assessment

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Making a Diagnosis (cont.)PEX:

Palpable nodes.

History:

30lbs weight loss, unintentional

Dx

: Cancer

Is there more than one cancer?

Lymph node biopsy

Hodgkin’s lymphoma

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RCA

Starts with event

Patient fall on 10-7.

What immediately preceded the fall?

Pt

out of bed, unknown to floor staff.

Should patient have been out of bed?

Was on fall precautions, ruby slippers and bed alarm.

Were these measures active?

Pt

wearing ruby slippers. Fall precautions active. Bed alarm off.

Why was bed alarm off?

Pt

had procedure. Medical staff deactivated bed alarm for procedure and did not reactivate.

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TimelinePatient fall.

Procedure performed, requiring deactivation of bed alarm.

Bed alarm not reactivated.

Patient attempted to ambulate.

Fall.

Corrective action.

Educate on bed alarm use.

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Image:

Duke University, DCFM.

James Reason, 1990

Swiss Cheese Model

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Types of ErrorsIneffective Hand offs

Signout

, ED to floor, OR to PACU

Latent Errors

“That’s just asking for a problem”

Heparin in different concentrations, nearly identical vials

Active Errors

Incorrectly applying ECG leads

Knowledge Errors

Not recognizing or acting on data

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Location of ErrorHealthcare specific

Blunt end

vs

Sharp end.

Blunt end:

All the support and ancillary services that surround the patient-provider interaction

Pharmacy, Shipping and Receiving, the power company, device manufacturers,

pharma

.

Sharp end:

Refers to sharp end of the scalpel

MDs, LIPs, technicians, nursing, PT, OT, RT.

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Outline (cont.)

Scope of the problem

Macro level

Micro level

Yale New Haven data

When errors occur

Disclosure and reporting

Root cause analysis

Swiss Cheese model

Corrective actions

Pronovost

&

Semmelweis

Special Guest

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Systems Engineering

Did you ever wonder why the Oxygen, Medical Air and Vacuum wall adapters are different shapes?

Adverse event. Ventilator connected to nitrous rather than oxygen in an OR via wall adapter.

Now that the adapters are, different shapes, it is impossible to put a green oxygen tree into a non-oxygen wall adapter.

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Peter Pronovost

CVC checklist

18 month period in Michigan

Saved $100 million

Saved 1500 Lives

N. Engl. J. Med.

355

(26): 2725–32

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CVC checklistDoctors should:

Wash their hands with soap.

Clean the patient’s skin with

chlorhexidine

antiseptic.

Put sterile drapes over the entire patient.

Wear a sterile mask, hat, gown and gloves.

Put a sterile dressing over the catheter site.

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Peter Pronovost (cont.)

“The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is ensuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.”

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Father of clean hands.

“Savior of Mothers.”

Reduced mortality from 10-30% to 1%.

Only intervention: Washing of hands.

Died from sepsis at age 47.

Ignaz

Semmelweis

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Are you the next Semmelweis or Pronovost?

Patient errors and near misses happen at every hospital in the world. Yale is no different.

We are presented with an opportunity to make Yale New Haven Hospital and the Yale School of Medicine a beacon for patient safety.

Magnet Status

EMR

Safe patient flow

Medical errors are an opportunity to improve.

Seize the opportunity.

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Your mission, should you choose to accept it…Actually, it is not a choice.

Your assignment:

Follow you teams patients closely. Any unexpected death, bad outcome, readmission, identified error – record the name and MR number.

Patient must be in Epic and the details of the event must also be in Epic

Bring this case to a session at the end of the clerkship for a real time Morbidity and Mortality session.

Blame free environment.