LORI SEARGEANT, MA, RHIA HS460 PROJECT DESIGN AND MANAGEMENT FOR HEALTHCARE

UNIT 8 OVERVIEW Read Chapter 9: The Human Face of Medical Error. Participate in seminar: compare and contrast, in detail, iatrogenic negative effects and medical errors. Give examples of each. Work on Power Point Presentation due in Unit 9. Quiz on Unit 7 material (2 essay questions).

CHAPTER 9 THE HUMAN FACE OF MEDICAL ERROR MCLAUGHLIN AND KALUZNY Continuous quality improvement in healthcare, 3 rd Edition Wednesday, April 18th

MEDICAL ERRORS Errors occur when a process does not go as planned Most frequent errors occur when a step in an established process is omitted Several notable articles published bringing medical errors to the public’s attention Proven methods for determining the etiology of human error exist in many industries (airline safety and nuclear reactor safety) Feldman and Robin (1997) and Eagle et al (1992) introduce the failure analysis to healthcare

CHARACTERISTICS OF HIGH RELIABILITY ORGANIZATIONS Focus on failures, not just successes Avoid disasters, yet focus on errors early Study the process in depth; do not focus on simplification Emphasize knowledge; gain it from the front line staff; listen and respect the experience at all levels Build resilience to overcome errors when they do occur Mindful Culture Reporting culture Just culture Flexible culture Learning culture

GEMS Generic Error Modeling System Developed by James Reason in 1990 Must be intention in the sequence of action for an error to occur Failures may occur because of errors in the plan or the execution of the plan A tragic outcome need not involve an error GEM’s Basic Error Types Skill-based slips (and lapses) Rule-based mistakes Knowledge-based mistakes Violations of rules or norms.

GEMS CLASSIFICATION Action vs. inaction Both lead to organization and system design faults Action Planning Errors Knowledge-based mistake Rule-based mistake Execution Errors Skill-based slip Skill-based lapse Motivation (violation) Sabotage Others Inaction Knowledge-based mistake Rule-based mistake

GEMS CLASSIFICATION Planning Errors Knowledge-based mistake Rule-based mistake Execution Errors Skill-based slip Skill-based lapse Motivation (violation) Routine Optimizing Necessary or situational

RESPONSE TO ERROR Countermeasures for skill-based errors Attention getters (e.g. reminders) Error detection In-line inspection Error limitation (usually data input limits) Checklists Resource input standards Substitute a rule

RESPONSE TO ERROR Countermeasures for rule-based errors Search for alternative response Sharing information about past errors Decision support systems Using simulation Countermeasures for knowledge-based errors Continuing education Training on recognizing and avoiding biases Develop decision support systems Peer review of infrequent procedures

MOTIVATIONAL ISSUES Overspecialization of tasks Lack of coordination, communication and cooperation Diffusion of responsibility Goal displacement Blame Management-staff conflicts Norms encouraging risky taking and rule bending

SEMINAR DISCUSSION Compare and contrast, in detail, iatrogenic negative effects and medical errors. Give examples of each.

PLAN FOR UNIT 9 Read Case 1 in the Text Respond to the discussion board Participate in seminar: At Intermountain Health Care, a portion of the salaried physicians’ compensation was for a performance-based bonus (10%). In light of patients being noncompliant, do you feel this is fair? Defend your answer. Submit your project Power Point Presentation Quiz on Unit 8 material (2 essay questions)