Patient safety

What is patient safety?

 efforts to minimize preventable harm to a patient

 includes all aspects of :
What is human factors?
 correct and effective medication
 safe injections
 standards for surgery and other invasive procedures
 certain degree of unsafety exists in any medical and care-giving intervention;
however, these risks can be minimized
 t is estimated that one in every 10 patients is harmed while receiving hospital
care
 Importance in health care?

• only recently been acknowledged as an essential part

of patient safety

• a major contributor to adverse events in health care

• all health-care workers need to have a basic

understanding of human factors principles
 Human factors experts
 - design improvements in the workplace and the equipment to fit human
capabilities and limitations

 - make it easier for the workers to get the work done the right way

 -decrease the likelihood of errors occurring

 The range of workers

 good human factors design in health care •order medications electronically

accommodates the entire range of workers
•hand off information
•move patients
 not just the calm, rested experienced clinician
If all of these tasks become easier for
the health-care
 also for inexperienced health-care workers who provider, then patient safety can
might be stressed, fatigued and rushing improve.
 Traps in health care?

• look-alike and sound-alike

pharmaceuticals

• equipment design
○ e.g. infusion pumps
Avoidable confusion is everywhere…

US Department of Veteran affairs

 Health care is
increasingly complex

Gaba
 Because the human brain is ….

• very powerful

• very flexible

• good at finding shortcuts (fast)

• good at filtering information

• good at making sense of things

Are the lines crooked or straight?
Optillusions.com
 The fact that we can misperceive
situations despite the best of
intentions is one of the main reasons
that our decisions and actions can
be flawed such that …

Human beings make

“silly” mistakes
 One definition of “human
error” is “human nature”

ERROR IS THE INEVITABLE DOWNSIDE

OF HAVING A BRAIN!
 The context of health care

When errors occur in the workplace the consequences can be a

problem for the patient

○ a situation that is relatively unique to health care

 What is an error?
• the failure of a planned action to achieve its
intended outcome

• a deviation between what was actually done

and what should have been done
Reason

• A definition that may be easier to remember

is:
○ “Doing the wrong thing when meaning to do the
right thing.”
Situations associated with an
increased risk of error
• unfamiliarity with the task*
• inexperience*
• shortage of time
• inadequate checking
• poor procedures
• poor human equipment interface

* Especially if combined with lack of supervision

Individual factors that
predispose to error
• limited memory capacity
• further reduced by:
○ fatigue
○ stress
○ hunger

○ illness
○ language or cultural factors
○ hazardous attitudes
 Fatigue

24 hours of sleep deprivation has performance

effects
~
blood alcohol content of 0.1%

Dawson – Nature, 1997

 What is an error?

• the failure of a planned action to achieve its

intended outcome

• a deviation between what was actually done

Reason
and what should have been done

• A definition that may be easier to remember

is:
○ “Doing the wrong thing when meaning to do the
right thing.”
Situations associated with an
increased risk of error
• unfamiliarity with the task*
• inexperience*
• shortage of time
• inadequate checking
• poor procedures
• poor human equipment interface Vincent

* Especially if combined with lack of supervision

Individual factors that
predispose to error
• limited memory capacity
• further reduced by:
○ fatigue
○ stress
○ hunger

○ illness
○ language or cultural factors
○ hazardous attitudes
Stress and performance

Performance level
Area of
“optimum”
stress
Low stress High stress
Boredom Anxiety,
panic
Stress level
The relationship between stress and performance
Yerkes, R. M., & Dodson, J. D. (1908) The relation of strength of stimulus to rapidity of habit-formation.
Journal of Comparative Neurology and Psychology, 18, 459-482
 Don’t forget ….
If you’re
 H ungry
H
 A ngry A
 L ate
or
L
 T ired ….. T
 Apply human factors
thinking to your work
environment
1. Avoid reliance on memory
2. Make things visible
3. Review and simplify processes
4. Standardize common processes and procedures
5. Routinely use checklists
6. Decrease the reliance on vigilance
UNDERSTANDING SYSTEMS
AND THE IMPACT OF
COMPLEXITY ON PATIENT
CARE
 A “system”
ANY COLLECTION OF TWO OR MORE INTERACTING PARTS, OR

“AN INTERDEPENDENT GROUP OF ITEMS FORMING A UNIFIED

WHOLE”

NPSEF (p. 202)

 A “complex system”
many interacting parts

difficult if not impossible to predict the behaviour of the system based

on a knowledge of its component parts
Health care is a
complex system

Gaba
COMPLEXITY = INCREASED
CHANCE OF SOMETHING
GOING WRONG!
Two schools of thought
regarding iatrogenic injury
o traditional or person approach
* the “old” culture
* “just try harder”

o systems approach
* the “new look”

You may encounter a bit of both in your

“journey”
 Person approach

see an errors as the product of carelessness

remedial measures directed primarily at the

error-maker

o naming
o blaming
o shaming
o retraining

Perspectives on error
 An individual failing?
Doesn’t work!
o people don’t intend to commit errors
only a very small minority of cases are deliberate violations

o won’t solve the problem - it will make it worse

o countermeasures create a false sense of security
“we’ve ‘fixed’ the problem”
o clinicians will hide errors
o may destroy many clinicians inadvertently
the second victim
 Why investigate?

 the more we understand how and why these

things occur, the more we can put checks in
place to reduce recurrence

 strategies might include:

 education
 new protocols
 new systems
 Multiple factors
usually involved
 patient factors
 provider factors
 task factors
 technology and tool factors
 team factors
 environmental factors
 organizational factors
 Reason’s “Swiss cheese” model
of accident causation

Some holes due

to active failures Hazards

Other holes due to

Losses latent conditions

Successive layers of defences, barriers and safeguards

System defences
Reason’s - Defences

VA NCPS
 Characteristics of high
reliability organizations
(HROs)
o preoccupation with failure
o commitment to resilience
o sensitivity to operations
o a culture of safety
 Key principles from
HRO theory
o maintain a powerful and uniform culture of safety
o use optimal structures and procedures
o provide intensive and continuing training of individuals and teams
o conduct thorough organizational learning and safety management
Being an effective team player
 What is a team?

A team is a group of two or more individuals

who:

o interact dynamically
o have a common goal/mission
o have been assigned specific tasks
o possess specialized and complementary skills
 Understanding and
and learning from error
 Error

a simple definition is:

 “Doing the wrong thing when meaning to do the right thing.”
Runciman

a more formal definition is:

 “Planned sequences of mental or physical activities that fail to
achieve their intended outcomes, when these failures cannot
be attributed to the intervention of some chance agency.”
Reason
 Error

a simple definition is:

 “Doing the wrong thing when meaning to do the right thing.”
Runciman

a more formal definition is:

 “Planned sequences of mental or physical activities that fail to
achieve their intended outcomes, when these failures cannot
be attributed to the intervention of some chance agency.”
Reason
 Note: violation

A deliberate deviation from an accepted protocol or standard of care

 Error and outcome

 error and outcome are not inextricably linked:

 harm can befall a patient in the form of a complication of care without an error
having occurred
 many errors occur that have no consequence for the patient as they are
recognized before harm occurs
 Human beings make “silly”
mistakes
Regardless of their experience, intelligence,
motivation or vigilance, people make mistakes
 Health-care context is
problematic
 when errors occur in the workplace the consequences can be a
problem for the patient
 a situation that is relatively unique to health care

 in all other respects there is nothing unique about “medical” errors

 they are no different from the human factors problems that exist in
settings outside health care
 Atte ntio na l s lips
o f a c tio n

S kill -b a se d slip s
a nd la ps e s

L a p se s o f
m e mo ry

Errors

R ule -b a s e d
m is ta k e s

M ista ke s

K no w le d g e -b a se d
m ista ke s

Reason
Situations associated with an increased
risk of error
 unfamiliarity with the task*
 inexperience*
 shortage of time
 inadequate checking
 poor procedures
 poor human equipment interface
Vincent

* Especially if combined with lack of supervision

Individual factors that
predispose to error
 limited memory capacity

 further reduced by:

 fatigue
 stress
 hunger
 illness
 language or cultural factors
 hazardous attitudes
 Don’t forget ….

If you’re
 H ungry
H
 A ngry A
 L ate
or
L
 T ired ….. T
 A performance-shaping factors
“checklist”
 I Illness
 M Medication
 prescription, alcohol and others
 S Stress
 A Alcohol
 F Fatigue
 E Emotion

Am I safe to work today?

Jensen, 1987
 Incident monitoring

 involves collecting and analysing information about any events that could
have harmed or did harm anyone in the organization

 a fundamental component of an organization’s ability to learn from error

 Removing error traps

 a primary function of an incident reporting system is to identify recurring

problem areas - known as “error traps” (Reason)

 identifying and removing these traps is one of the main functions of error
management

Error traps
Hindsight Bias

Before the After the Incident

Incident

Modified from Cook, 1997

 Root cause analysis

when you have a problem at work? Do you jump straight in and

treat the symptoms, or do you stop to consider whether there's
actually a deeper problem that needs your attention
 RCA model

 a rigorous, confidential approach to answering:

 What happened?
 Why did it happen?
 What are we going to do to prevent it from happening again?
 How will we know that our actions improved patient safety?
 RCA model

 focuses on prevention, not blame or punishment

 focuses on system level vulnerabilities rather than individual

performance

- communication - environment/equipment
- training - rules/policies/procedures
- fatigue/scheduling - barriers
 Personal error
reduction strategies
 know yourself
 eat well, sleep well, look after yourself …
 know your environment
 know your task
 preparation and planning
 “What if …?”
 build “checks” into your routine
 Ask if you don’t know!
Understanding and managing
clinical risk
 Why clinical risk is relevant to patient
safety
 clinical risk management specifically is concerned with improving the quality and safety of
health-care services by identifying the circumstances and opportunities that put patients at risk
of harm and acting to prevent or control those risks
4-step process to manage clinical
risks
 identify the risk
 nspect the workplace
 Physical work environment

 Equipment, materials and substances used

 Work tasks and how they are performed

 Work design and management.

 Make a list of all the hazards you can find

 Consult your workers

 Review available information

 assess the frequency and severity of the risk

 reduce or eliminate the risk
 cost the risk
Engaging with patients and carers

 actively encourages patients and carers to share information

 shows empathy, honesty and respect for patients and carers
 communicates effectively
 obtaining informed consent
 shows respect for each patient’s differences, religious and cultural beliefs,
and individual needs
 describes and understands the basic steps in an open disclosure process
 apply patient engagement thinking in all clinical activities
 demonstrates ability to recognize the place of patient and carer
engagement in good clinical management.
Gaining an informed consent

 the diagnosis
 the degree of uncertainty in the diagnosis
 risks involved in the treatment
 the benefits of the treatment and the risks of not having the
treatment
 information on recovery time
 name, position, qualifications and experience of health
workers who are providing the care and treatment
 availability and costs of any service required after discharge
from hospital
Open disclosure

Informing patients and their families of bad outcomes of medical treatment, as distinguished
from bad outcomes that are expected from the disease or injury being treated

Key principles of open disclosure

 openness and timeliness of communication

 acknowledgement of the incident
 expression of regret/apology
 recognition of the reasonable expectations of the
patient and their support person
 support for staff
 confidentiality
Open disclosure
◘
INTRODUCTION TO MEDICATION
SAFETY
 Performance requirements

Acknowledge that medication safety is a big topic and an understanding of the area will
affect how you perform the following tasks:
• use generic names where appropriate
• tailor your prescribing for individual patients
• learn and practise thorough medication history taking
• know which medications are high risk and take precautions
• know the medication you prescribe well
• use memory aids
• remember the 5 Rs when prescribing and administering
• communicate clearly
• develop checking habits
• encourage patients to be actively involved in the process
• report and learn from medication errors
 Definitions

 side-effect: a known effect, other than that primarily intended, relating to the
pharmacological properties of a medication
 e.g. opiate analgesia often causes nausea
 adverse reaction: unexpected harm arising from a justified action where the correct process
was followed for the context in which the event occurred
 e.g. an unexpected allergic reaction in a patient taking a medication for the first time
 error: failure to carry out a planned action as intended or application of an incorrect plan
 adverse event: an incident that results in harm to a patient

WHO: World alliance for patient safety taxonomy

How can prescribing go wrong?

 inadequate knowledge about drug indications and contraindications

 not considering individual patient factors such as allergies, pregnancy,
co-morbidities, other medications
 wrong patient, wrong dose, wrong time, wrong drug, wrong route
 inadequate communication (written, verbal)
 documentation - illegible, incomplete, ambiguous
 mathematical error when calculating dosage
 incorrect data entry when using computerized prescribing e.g.
duplication, omission, wrong number
Look-a-like and sound-a-like
medications

 Celebrex (an anti-inflammatory)

 Cerebryx (an anticonvulsant)
 Celexa (an antidepressant)
Ambiguous nomenclature

 Tegretol 100mg  Tegreto 1100 mg

 S/C  S/L
 1.0 mg  10 mg
 .1 mg  1 mg
Administration involves …

 obtaining the medication in a ready-to-use form; may involve counting,

calculating, mixing, labeling or preparing in some way
 checking for allergies
 giving the right medication to the right patient, in the right dose, via the
right route at the right time
 documentation
How can drug administration
go wrong?

 wrong patient  right drug

 wrong route  right route
 wrong time  right time
 wrong dose
 right dose
 right patient
 wrong drug
 omission, failure to administer
 inadequate documentation
Which patients are most at risk of
medication error?

 patients on multiple medications

 patients with another condition, e.g. renal impairment, pregnancy
 patients who cannot communicate well
 patients who have more than one doctor
 patients who do not take an active role in their own medication use
 children and babies (dose calculations required)
 In what situations are staff most likely
to contribute to a medication error?
 inexperience
 rushing
 doing two things at once
 interruptions
 fatigue, boredom, being on “automatic pilot” leading to failure to check and double-check
 lack of checking and double checking habits
 poor teamwork and/or communication between colleagues
 reluctance to use memory aids