patient Safety

Medical Error Management 1

2 Patient safety is the avoidance, prevention, and amelioration of adverse outcomes or injury from the process of health care Professor Charles A Vincent (2006)

3The freedom from accidental injury due to medical care or from medical error. (Institute of Medicine 2000) The National Patient Safety Agency (2003) has described patient safety as the process by which an organization makes patient care safer. This should involve:Risk assessment The identification and management of patient related risk The reporting and analysis of incidents And the capacity to learn from and follow up incidents and implement solutions to minimize the risk of them recurring.http://www.clinicalgovernance.scot.nhs.uk/section5/definition.asp 4 () SafeEffective

5the very first requirement in a hospital [is] that it should do the sick no harm Notes on hospitals (Florence Nightingale, 1863)

6(Haig, 2004)Safety is like peeling an onion; the more you look, the more you find, the more you find, the more you cry!

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References: Brennan et al Incidence of adverse events and negligence in hospitalised patients N EnglJ Med1991; 324: 370-376 Thomas et al Costs of Medical Injuries in Utah and Colorado Inquiry1999; 36: 255 -264Wilson et al The quality of Australian health care study Med J Aust1995; 163:458 -471Vincent, Neal and Woloshynowych BMJ 2001: 322: 517-519

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1244,000-98,000 deaths estimate does NOT include deaths from ambulatory sites (nursing homes, home-health, office-based practices)

Deaths from Adverse Events more common than:Breast CancerMotor Vehicle AccidentsAIDS

13Despite what you hear advertised

Be sure to note that the numbers of deaths due to medical errors are ONLY for hospitals (not ambulatory care, not long-term care, etc.) so is probably just the tip of the iceberg.

( 2006) - 3.72086451 Brennan et al. (1991)16.6*1417928 Wilson et al. (1995)10.810142 Vincent et al. (2001)9.0109717Schioler et al. (2001)11.2657913 Davis et al. (2001)14.57787 Michel et al. (2004)7.5374520 Baker et al. (2004)14National Patient Safety AgencyCreated in 2001 following publication of: An Organisation with a Memory, which looked at learning from adverse incidents in the NHS; and

Building A Safer NHS for Patients, which set out the governments plans to address the recommendations.15 Safety EffectivenessPatient-centerednessTimelinessEfficiency Equity

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1716-10 . . 3 ( )

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10 = 900000

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400

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1 19 (Error):

(Medical Error) .

20 error of execution error of planning

: / / 22Human Commission

Human Omission : (Active Failure) : . . (Latent Failure) : . . . :24ERROR TYPES based on the work of Reason, adapted by NPSA UnsafeactsUnintendedactionsIntendedactionsMistakesViolationsBasic error typesSkill based errorsAttention failuresSkill based errorsMemory failures

Rule & Knowledge Based errorsRoutineReasonedReckless & MaliciousSlipsLapses25James Reason describes the different error types. These have been adopted by the NPSA to be more usable within healthcare and describe the types of active failures which may occur.

Shirley to send more info ( ) ( )

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26James Reason describes the different error types. These have been adopted by the NPSA to be more usable within healthcare and describe the types of active failures which may occur.

Shirley to send more info (Violation)1- routine violation . .

: .27 (Violation)2- reasoned violation . .

: .28 (Violation)3- reckless violation .

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29 (Violation)4- violation malicious .

:Dr. Death: The Beverley Alittand Harold Shipman cases30 ( ) ( )

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31James Reason describes the different error types. These have been adopted by the NPSA to be more usable within healthcare and describe the types of active failures which may occur.

Shirley to send more info

mistake 1- knowledge based mistake .

2- Rule based mistake .

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33James Reason describes the different error types. These have been adopted by the NPSA to be more usable within healthcare and describe the types of active failures which may occur.

Shirley to send more info

- lapse ( )

34- slips -

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Patient Safety IncidentHow do accidents happen?Swiss Cheese ModelLatent FailuresService Delivery ProblemsAccidents waiting to happen37

Patient Safety IncidentHow do accidents happen?Performance influencing factorsContributing factorsstuff happens38

Patient Safety IncidentHow do accidents happen?Active failuresCare delivery problemssomeone made a mistake..39

Safety IncidentControls and defencesBarriersand no-one stopped them40

Swiss Cheese theory exercise

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42 / Contributory Factors- . .

Contributory, influencing or causal factors ,are things that contributed to the incident.

43 Influencing factors: / (immediate- proximate causes ).

( ) causal factors : ( root causes ). / Contributory Factors- 44

Contributory Factors

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46http://www.thinkreliability.com/Root-Cause-Analysis-CM-Basics.aspx

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48 :

. [1] Person Approach [2] System Approach

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= .

= 501- Personal Approach .1 . .2 ( ) . .3 .4 . .51 : .5 .6 . 522- : System Approach . . .53We cant change the human condition, but we can change the conditions under which humans work.

Prof James Reason

System or person?54Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a total mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wloheSystem or person?55 : ( ) .

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59 : / : methiciline resistant Staphyloccous aureus (MRSA) 12 . (10 ) 60 :

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(Weak Failsafe) .

(Strong failsafe).

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