Overview of the Science of Safety in Healthcare Jim Bien, MD, FAAP Vice President Quality and Patient Safety

“All men make mistakes, but a good man yields when he knows his course is wrong, and repairs the evil. The only crime is pride.” Sophocles, Antigone "Every system is perfectly designed to get the results it gets." Paul Batalden, M.D.

Outline What happened last week? Error is common and harmful Conceptualizing error Responding to these risks

What happened last week?

Error is Common and Harmful

Institute of Medicine 1999 Estimated that ,000 Americans die each year in hospitals from preventable medical errors. Called for comprehensive effort to make care safer.

Reviewed 4 studies published from “the true number of …deaths associated with preventable harm …estimated at more than 400,000 per year.” Third leading cause of death, behind heart disease and cancer. Journal of Patient Safety. 9(3): , September 2013

Analysis of admissions in 10 hospitals from 2002 – 2007 N Engl J Med 2010; 363:

2003. Random sample of adults living in metropolitan areas of the United States received ~54% of recommended care for preventive, acute and chronic disease management. N Engl J Med 2003; 348:

N Engl J Med 2007; 357:

Conceptualizing Error in Health Care Medication (dose/time/route/patient/drug) Procedural (i.e. retained foreign body) Diagnostic (heuristics i.e. anchoring/availability) Human Factors and Errors at Person- Machine Interface (design of equipment/space) After Robert M. Wachter, MD

Conceptualizing Error in Health Care Transition and Handoff (i.e. telemetry drops, transferring units) Teamwork and Communication (authority gradient) Hospital Acquired Infections (i.e. SSIs) Preventable Complications of Healthcare (i.e. Falls) After Robert M. Wachter, MD

Conceptualizing Error in Health Care Why do errors occur? –Humans are fallible –System attributes allow for human missteps to result in errors Overly complex Inadequately designed Tolerate unbeneficial variation in practices Opportunities to improve teamwork

‘People are to blame’ approach to error: Focuses on the errors of the people involved with the work. Assumes that errors are failures of human behaviors and therefore unsafe acts arise from forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness. Countermeasures focus on reducing the variation in human behavior Removing poor performers

Flaws with the Blame Approach to Error Humans are fallible Few errors are caused by egregious disregard for rules or policies Blaming individuals greatly impacts the reporting of errors; reducing insight into system weaknesses.

The “System is Flawed’ approach to error Humans are fallible and will err Important issue is not ‘who?’, but ‘how?’ ‘why?’ Errors are understood as consequences of system factors Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work.

Latent Weaknesses and Active Errors

Responding to these risks Design the system to be error-proof –Standardize where feasible Reduce unnecessary variation Automate wisely –Create independent checks –Learn from defects The principles of safe design apply to technical work and teamwork

Error-proofing the System

High reliability organizations -HROs “operate under very trying conditions all the time and yet manage to have fewer than their fair share of accidents.” HRO’s practices decrease the probability of an event occurring. HROs operate as to make systems ultra-safe.

HRO Principles of Organizing Prevention practices –Preoccupation With Failure –Reluctance to Simplify –Sensitivity to Operations Containment practices –Commitment to Resilience –Deference to Expertise

Preoccupation With Failure Sensitive to defects of all types, even ‘good catches’ Interpret defects as signals of system’s weakness Cultivate a healthy paranoia. Always asking: –What could go wrong here? –What am I missing? –How could this fail? Worry about the temptation to treat unexpected events as no big deal – ‘normalizing’ something which should be understood as a failure

Deference to Expertise Makes an effort to see what those at the ‘sharp end’ know. Authority migrates to the people with the most expertise. Decisions are made on the front line. Does not mistake experts with expertise.

Challenges to High Reliability in Healthcare Industry largely decentralized and poorly integrated Lack of standardization in processes Misaligned financial, performance, and quality incentives 21st century technological and clinical advances stuck in 20th century workflow and management systems

Efforts for improving Safety at IUHA Culture of Safety defined by the Board as a foundational element of our Quality and Safety Plan Learning from Events How to report an event?How to report an event? Harm line: HARM (8-4276) Safety Rounds Just Culture Survey of Patient Safety Culture

Efforts for improving Safety at IUHA Lean process improvement –Simplifying design –Error-proofing Standardizing w/ evidence-based practices/bundles –Surgical ‘time-outs’/ Vent bundles etc Measurement and feedback –NSQIP –Quality Panels D.A.S.H.

Daily Awareness and Safety Huddle Team of leaders huddle to increase situation awareness 0905 ~ 0925 M-F Focus is a quick ‘look back’, and ‘look ahead’: –Unexpected/Surprising/Harm events last 24hours –Current-state readiness –Anticipated risks in next 24 hours Written report w/in 1hour widely distributed

“…appears to improve the –efficiency of information sharing among staff –enhance their sense of accountability and empowerment, and –strengthen their sense of community, which… may work together to establish a more collaborative culture that enables a collective awareness for reducing failures and improving patient safety.” BMJ Qual Saf 2013;22:899–906

Conclusion Humans are fallible Healthcare errors are a property of the system Events are clues to system weaknesses Safety requires thoughtful system design (including designing how teams work) Lean methodology is one method to redesign a system to reduce harm The habits of HROs are being applied in health care settings to reduce harm.

"If we keep doing what we have been doing, we'll keep getting what we've always gotten“ Paul Batalden, M.D.