Donald E. Lighter, MD, MBA, FAAP, FACHE. Director, IHQRE Professor, University of Tennessee

Transcription

1 Donald E. Lighter, MD, MBA, FAAP, FACHE Director, IHQRE Professor, University of Tennessee

2 The case for high reliability Case studies Medical errors Characteristics of health care HROs Industrial view Culture/values HRO tools applied to health care Mistake proofing

3 Sue Sheridan

4 Twins Thomas Boone and Zoe Grace Quaid nearly died in November 2007 at Cedars-Sinai Hospital in Los Angeles when they were mistakenly given a massive overdose of heparin. Instead of using HepLock, the highly diluted solution of the drug to maintain patency of an indwelling line, the twins instead received therapeutic heparin, which is ten times more concentrated. Hemorrhaging from every possible site, the babies nearly exsanguinated before the error was discovered and action taken to correct the mistake. The infants are the children of actor Dennis Quaid and his wife Kimberly, who have set up a foundation to discover ways to prevent medical errors

5 Alyssa Shinn, a baby born prematurely to a mother who had undergone in vitro fertilization, received a fatal overdose of zinc in her hyperalimentation solution, prepared by a part time pharmacist at Summerlin Hospital in Las Vegas. The error occurred because of multiple failures in the hospital pharmaceutical ordering system, including a failure of a pharmacy team to check the dose of zinc, which turned out to be 1,000 times the dose prescribed and reasonable for the baby. Multiple checks in the system failed, causing the lethal dose of zinc to be administered, resulting in the baby s death. The error resulted in an undisclosed financial settlement between the hospital and the family. Deadly Dose, ABC News, video available at March, 2008.

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7 Patient safety incidents Medicare data 1.12 million total patient safety incidents/41 million hospitalizations (~3%) $8.8 billion of excess cost Post-op indicators worsened - > accounted for ~72 percent of all the potentially preventable deaths Post-operative respiratory failure Post-operative pulmonary embolism or deep vein thrombosis Post-operative sepsis Post-operative abdominal wound dehiscence AHRQ Patient Safety Indicators with the highest incidence rates (~63.4% of total) Decubitus ulcer Failure to rescue Post-operative respiratory failure The fifth annual HealthGrades patient safety in American hospitals study, Available at: April,

8 Inpatient deaths HealthGrades Distinguished Hospitals 270,491 actual in-hospital deaths among patients who developed one or more of the 16 patient safety incidents, 238,337 deaths were attributable to patient safety incidents and potentially preventable Medicare patients who experienced a patient safety incident had a one-in-five chance of dying as a result of the incident Medicare patients in the HealthGrades Distinguished Hospitals for Patient Safety had a 43-percent lower risk of one or more PSIs compared to patients at the bottom ranked hospitals across all 13 PSIs studied. If all hospitals performed at the higher level: 220,106 fewer patient safety incidents 37,214 Medicare deaths avoided $2.0 billion savings during 2004 to

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10 Brief history 1987 Researchers at University of California Berkeley (Todd LaPorte, Gene Rochlin, and Karlene Roberts) examined: Aircraft carriers (in partnership with Rear Admiral (ret.) Tom Mercer on the USS Carl Vinson) Federal Aviation Administration s Air Traffic Control system (and commercial aviation more generally) Nuclear power operations (Pacific Gas and Electric s Diablo Canyon reactor)

11 Carriers have multitude of risks Operate with low rates of injury Focus on systems and error avoidance

12 Risks are high, stress levels high Technology intense Accident rates very low Learning from near misses

13 Originally designed to withstand a 6.75 magnitude earthquake from four faults, including nearby San Andreas and Hosgri faults Upgraded to 7.5 magnitude protection due to public protests and NRC oversight

14 Preoccupation with failure Reluctance to simplify interpretations Sensitivity to operations Commitment to resilience Deference to expertise

15 Making sure that we avoid harm to the people we treat and to the people who treat them Safety as everyone s job Patient and staff focus Dealing with complexity Appropriate monitoring Effective measures Leaders establish requirements to ensure mitigation of risk to staff and patients Systems approach Deming it s the system

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17 Lean Six Sigma FMEA RCA Error proofing poka yoke Emergency preparedness Just culture Eliminate blame System focus Accountability

18 Lean Management System term translated as mistake proofing Goal is to recognize errors as soon as they occur in the process so that they may be corrected before they propagate Purpose = ensure that conditions are set in the process environment to avoid errors, rather than correcting them Copyright IHQRE 2012 All rights reserved

19 Normal Text Celebrex Celexa Vinblastine Vincristine Tall Man Text CeleBREX CeleXA VinBLAStine VinCRIStine IHQRE (2012)

20 Traditional culture Captain of the ship doctrine Hierarchical structure Defer to physician Changing culture emphasis on teamwork Staff empowerment Crew resource management (TeamSTEPPS) Deployment at many institutions NSLIJ, UNC, OHSU, U of Pittsburgh, many others

21 The old way of dealing with human error was to scold people, retrain them, and tell them to be more careful My view is that you can t do much to change human nature, and people are going to make mistakes. If you can t tolerate them... you should remove the opportunities for error. Training and motivation work best when the physical part of the system is well-designed. If you train people to use poorly designed systems, they ll be OK for awhile. Eventually, they ll go back to what they re used to or what s easy, instead of what s safe. You re not going to become world class through just training, you have to improve the system so that the easy way to do a job is also the safe, right way. The potential for human error can be dramatically reduced. Chappell, L The Poka yoke Solution. Automotive News Insights, (August 5): 24i. LaBar, G Can Ergonomics Cure Human Error? Occupational Hazards 58(4):

22 Forgetfulness Inadvertent or sloppiness Misunderstanding Slow responses Wrong identification Lack of standardization Lack of experience Willful (ignoring rules or procedure) Surprise (unexpected machine operation, etc.) Intentional (sabotage) 25

23 Danger Hazard Preventive measures (active & latent failures) Unsafe acts (active failures) Preconditions (latent failures) Supervision (latent failures) Accident Rules, policies & procedures (latent failures)

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26 Patient-centered culture Optimize structures and procedures Intensive and continuing training of individuals and teams Capitalize on organizational learning and safety management

27 Commercial air travel Military systems, e.g. the aircraft carrier Nuclear industry Automotive engineering Manufacturing

28 Communication and teamwork will be the key

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