10/28/2011

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Reducing medical error and
increasing patient safety
Richard Smith
Editor, BMJ
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
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.
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.
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
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
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 its 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
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
Building a safe healthcare
system (from James Reason)
Principles
Safety is everybodys 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
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
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
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 Reasons bottom line
Fallibility is part of the human
condition
We cant change the human
condition
We can change the conditions
under which people work
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
Its a long, never ending job