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Patient Safety 1 - Systems

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Jason Werner

on 27 May 2016

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Transcript of Patient Safety 1 - Systems

MD slip in
order entry
Human factors:
Task overload
Patient Safety - I
System errors
Safety Culture
Patient safety culture
A little more down-to-Earth...
What Happened, and Why?
How Do We Decide?
"Culture eats change for breakfast..."
By the end of this session, you will have:
1. A framework for thinking about medical errors

2. A new vocabulary with which to discuss medical errors

3. An increased awareness of the importance of a culture that promotes safety.

4. An increased awareness of the need to be constantly alert for the potential for error and opportunities for intervention.
Our Goals
Phone call from the hospital Risk Management about an adverse event involving residents.

Patient w/ known Hgb SS, admitted with acute chest and concern for a new pulmonary embolism.

Blue Team intern wrote orders in EPIC.
HD#2 knee acutely swollen, drop in Hct, high PTT. H/O concerned about hemarthrosis

On review, team recognized that the orders were for 2X the correct dose of heparin (load and drip)

Likely hemarthrosis due to heparin overdose
Case Continued
Is there a difference??

Adverse Event

Near miss

Medical Error
How could this have
Patient diagnosed
knee hematoma
Anytime a patient suffers a negative outcome from an interaction with the healthcare system

Adverse events can both be preventable and unpreventable.

Examples of preventable adverse events include
Medication errors
Diagnostic errors
Procedural errors.

Different from, but similar to, Joint Commission - defined
Sentinel Event
Serious Event
Adverse events
An event or situation that did not produce patient injury, but only because of chance.

Can be due to patient factor or can be “caught” by system

Close call or near “hit”

"The errors that should scare you are the bad decisions...where nothing bad happens."
"Near Miss"
Medical Errors
Near Misses
Adverse Events
Harvard medical practice study, 1991
Utah and Colorado , 1992
44-98,000 people could die annually as a result of medical error
8.8-13.6% of these lead to death
2.9-3.7% of hospitalizations
Medical Error
Preventable > 50%
The numbers….
Swiss Cheese Model of Error
Reason, J. BMJ 2000;320:768-770
Copyright ©2000 BMJ Publishing Group Ltd.
"Adverse Event Review" or "Root Cause Analysis"
Process for identifying the multiple contributing factors that underlie adverse events or near misses

“Contributing factors analysis” or “systems analysis” are alternatives

3 Questions
What really happened?
Why did it happen?
How can we prevent it from happening again?
The reporting and analysis of adverse events are crucial to redesigning safer systems.

Easy to miss the point
Blame the individual
Draw the wrong conclusion

Systematic approach
Takes you from the sharp end (the individuals) and takes you up to the blunt end (the organizational processes)
Rationale – why do this?
Decision to Review
Select People and Gather Data
Determine Incident Chronology
Identify Care Delivery Problems
Identify Contributory Factors
Why? x 5
Making Recommendations & Developing an Action Plan
Event Analysis

Decision to Review
Patient safety officer(s)
Dr. Peter
Dr. Lowrie
Dr. Treadway
Network Risk Management

Select People and Gather Data
Team vs. interviews
Charts, orders, patient data, process data
Back to the Case
Lists of events
Time points
Determine Incident Chronology
Patient admitted from
Emergency Room
Patient diagnosed with
knee hematoma
Intern enters admit
Orders into CPOE
What do we know so far?
Intern orders heparin
Patient seen by
team and H/O attending
in morning
Interview with intern:
“I opened the EPIC order management screen and wrote for the bolus and infusion rates using her weight of 220 lbs and my expected goal PTT of 60-90. I signed the order and called the nurse, and asked her to hang the drip. Then I left to go admit the two other patients who were waiting for me. I was so busy. These night float shifts can be crazy. Oh, and the senior was covering from another team.”
Entered kgs instead of lbs
Pulmonary Embolism
For weight based algorithm fill in the information and click OK to enter order.
SMITH, SALLY, 1327892 DOB 3/26/58 LOCATION: CC6
Order Type: Renewal

New Order

Follow-up interview with intern:

“Why did I click on kgs instead of lbs? Well I had just finished a NICU rotation and was pretty tired that day. I was also interrupted while typing the order when my pager went off for the other two admissions. Looking back, I guess I was distracted.

“Also now that I think back, when you look at the computer screen to order the drug and enter the weight, the way you pick lbs or kgs is in a drop down and it is easy to click on one when you meant the other.
Other frontline providers?
Human factors:
Task overload
Patient diagnosed with
knee hematoma
MD Slip
in ordering
Intern enters admit
Orders into CPOE
Intern orders heparin
Interview with pharmacist

“I was new to Glennon when this happened. When I got the order I noted the bolus was too high and that the rate was well beyond what I have usually done. I tried to reach the resident but couldn’t reach him – never called back. I hadn’t been told how to get a hold of the floor staff. So I left a sticker on top of the bag for the RN to call the doctor.

“I heard the next day she never saw the sticker and ran the heparin at the higher dose.”
Interview with RN
“The heparin bag was brought over by the Pharmacy Tech. I calculated the rate and administered the drip per the protocol.

"Overnight the PTT’s were really high. The covering intern had me adjust the dose down twice. I was surprised to find out later it was too high but I wouldn’t have known – again, we don’t use heparin here that often.

"It has been a while since I have given it or had training as well.”
Incident chronology

Dispensed too
much heparin
RN administered
too much heparin
Nurse adjusts dosing
over night
Nurse gets bag
from pharmacy
and hangs dose
Pharmacist leaves
sticker and sends
bag to floor
tried to
reach MD
notes dose
too high
Intern enters admit
orders into EPIC
System (latent) failures
Arise from decisions that are made when systems are first constructed or evolve over time.


information or policies used to create protocols
environment or equipment design
communication failures
human resources (incl. staffing and training)

Can lie dormant for years and only become evident when local circumstance conspire with an active failure of an individual and an accident occurs.

Five why’s
institutional factors
Identifying Contributory Factors
work environment
organizational & management
task & technology
Vincent C, NEJM 2003, 348;11
Determining Contributing Factors
Could a Stronger Safety Culture
Have Stopped this Error?
Reason, J. Human Error
Reason, J. BMJ 2000;320:768-770
Copyright ©2000 BMJ Publishing Group Ltd.
If you are not sure if something is right, assume it’s wrong and get help or seek advice before taking the next step.
Pharmacist unsure…did not know how to get a hold of the floor staff
First Principle of High Reliability Organizations: Preoccupation with Error

Regard small, inconsequential errors or “close calls” as a symptom that something is wrong

Everyone views their role to include reporting errors and stopping to check for errors on the team

Feel safer speaking up: no fear of reprisals, expect support and praise for asking questions
Safety Minded People and Teams can make complex systems safer
The point?

Fragmented systems that put good people in bad
situations inevitably lead to bad outcomes.
Jason Werner, MD
Assistant Professor, Pediatric Critical Care

28 Jan 1986
11:38.00 EST
29 deg F
I am appalled, applled by your recommendation.
My God, Thiokol! When do you want me to launch, next April?
-SRB Project Manager George Hardy
How to talk about
How did the system of
care delivery contribute?
Intern orders
Dispensed med
without complete
MD slip in
order entry
Human factors:
Task overload
Incident chronology

Dispensed too
much heparin
RN administered
too much heparin
Nurse adjusts dosing
over night
Nurse gets bag
from pharmacy
and hangs dose
Pharmacist leaves
sticker and sends
bag to floor
tried to
reach MD
notes dose
too high
Intern enters admit
orders into EPIC
Intern orders
Dispensed med
without complete
EPIC design problem
Training problem
Intern accidentally chose kgs instead of pounds in the computer
Nurse unsure…not familiar with using heparin
Contributing Factor Analysis
* Also known as fishbone diagram
CPOE dropdown menu for weight
Intern distracted leading to slip
No standing communication policy between MD and Pharmacy
Pharmacist not trained on how to reach floor RN
Intern with multiple simultaneous admits
RN not recently trained in using heparin IV
Heparin Overdose
Cause-Effect Diagram*
Making Recommendations & Developing an Action Plan
What do we need to think about here?

Ranking the Effectiveness of
Error-Reduction Strategies
Most Effective (Strong)

Forcing functions and constraints

Automation and computerization

Standardization and protocols

Checklists and double-check systems

Rules and policies

Education and information

Exhortation: “Be more careful. Be vigilant.”

Least Effective (Weak)

Gosbee JW, Gosbee LL, eds. Human Factors Engineering to Improve Patient Safety. Oakbrook IL: Joint Commission Resources 2005
How do you prevent customers from leaving their ATM cards behind?
Strong Actions: Swipe card only
Intermediate Actions: Beeping
Weak Actions: Signs

Dispensed too
much heparin
Making Recommendations &
Developing an Action Plan
Reminders about heparin safety

Inservice on heparin dosing for PE

Hospital policy on RN x 2 check

EPIC order set for PE protocol

EPIC adjusted to only allow wt in Kg





LEVEL Characteristics from Vincent Model Analysis of Heparin Overdose

Task / Tech




Organization /

Complexity of condition
Language and communication
Personal / social factors

Availability / Use of Protocols
Availability / Accuracy of test results

Knowledge and skills
Motivation and attitude
Phys./Mental Health

Verbal/written communication
Supervision, willingness to seek help
Team Leadership

Staffing and mix of skills
Pt. workload
Design, maintenance of equipment
Administrative support

Financial resources and constraints
Policy standards and goals, safety culture
and goals

Regulatory and legal environment
Hgb SS -> increased risk of PE

Intern did not review protocol before

RN not familiar with heparin

Pharm to MD/RN communication
R.Ph. supervision unclear

EPIC dropdown too easy to enter wrong
Intern workload

RN did not enlist CNS support
1 Feb 2003
Rick D. Husband
William C. McCool
Michael P. Anderson
Kalpana Chawla
David M. Brown
Laurel Clark
Ilan Ramon
Society for Hospital Medicine's Quality and Safety Educators' Academy
...go to this meeting. Seriously....

Anjala V. Tess, MD
Harvard Medical School
Beth Israel Deaconess Medical Center

Jennifer S. Myers, MD
University of Pennsylvania
Hospital of the University of Pennsylvania
Francis R. Scobee
Michael J. Smith
Ronald McNair
Ellison Onazuka
Judith Reznik
Greg Jarvis
Christa McAuliffe
Sometimes automated systems help, and sometimes
they annihilate $600B worth of value in 5 minutes
Full transcript