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Error Recognition, Reporting, and Reduction
2013 Yvonne Murphy, MD Associate Program Director Director of Behavioral Science MacNeal Family Medicine Residency
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Educational Objectives:
To insure full participation of residents in patient safety initiatives State the relevance of error recognition, reporting, and reduction for residents Name types of medication errors and diagnostic errors Describe error reduction strategies for use in clinical practice
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Relevance Errors happen everyday Many of these errors are preventable
One in every 4 inpatients experiences a medical error The equivalent number of people on a jumbo jet die every day in US hospitals due to error (44-98,000/yr) 40,000-80,000 deaths (est) per year due to diagnostic errors Many more are harmed Many of these errors are preventable
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Relevance IOM – most powerful way to reduce error in medicine is to focus on system level improvements In order to identify the opportunities for systems change, near misses and other incidents need to be recognized, reported, and analyzed Resident doctors spend a great deal of time in patient care in hospitals and can often readily identify these opportunities
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Examples of Errors from Our Program
Insert your own and classify type of error and if error with or without harm, near miss, or unsafe condition
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Recognizing Errors Definitions
Error (IOM): failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim Diagnostic Error (Australian Pt Safety Foundation): Unintentionally delayed Wrong (another dx made before correct one) Missed (correct dx never made)
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Recognizing Errors From “Diagnostic Error in Internal Medicine” by Graber, Franklin, and Gordon. Arch Int Med 2005 No fault (7%) Masked or unusual presentation of disease Uncooperative or deceptive patient Systems Related (19%) Combined Cognitive Errors (28%) 46% -faulty knowledge -faulty data gathering -faulty synthesis
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Recognizing Errors Cognitive Errors
Faulty knowledge (n=11) Insufficient knowledge of condition n=4 Insufficient diagnostic skill (reading EKG or CXR) n=7 Faulty Data Gathering (n=45) -incomplete/faulty Hx, PE, ordering or performing of tests including screening Faulty Synthesis (n=159)
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Recognizing Errors Cognitive Errors
Faulty Verification (n=106) -failure to consider other possibilities once an initial dx made – most common of any single type error -failure to order or follow up on appropriate test -failure to consult -failure to periodically review situation -failure to gather other information or verify with patient -overreliance on someone else’s opinion
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Add Descriptions of Your Hospital’s Safety Programs
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Reporting Errors Detail how to report errors in your hospital
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Error Reduction Techniques:
Specific techniques are shown to reduce chance of error when used regularly
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Error Reduction Techniques: Medication Errors
Five R’s for administration of drug: (includes immunizations) Right patient Right drug (CHECK ALLERGIES) Right dose (including strength; LOOK IT UP) Right route Right frequency Also write indication for PRN
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Error Reduction Techniques: Medication Errors
Pediatric Dosing (Jose Martinez example): Document both weight and mg/kg on order Weight – check in pounds or kilograms Is dosing mg/kg/DAY or mg/kg/DOSE? Use a buddy system to independently calculate and check result of calculation and correct writing of order
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Error Reduction Techniques: Medication Errors
Three way communication Especially with verbal orders (avoid if possible) Verbal communication Read back Repeat/confirm correct Supervision/peer checking -double check written orders esp high risk medications (potassium, insulin, anticoagulants)
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Include data on errors in your hospital if available
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Error Reduction Techniques: Diagnostic Errors
Know common cognitive errors and self monitor STAR – stop, think, act, review Develop a complete differential diagnosis Premature closure and missing correct diagnosis most common cognitive error Use Isabel to double check Validate (does this seem right to me?) Verify (external check with an expert source like a consultant or reference; but don’t rely solely on a consultant’s opinion)
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Error Reduction Techniques: Diagnostic Errors
Reporting systems issues: -Lack of or incorrect reporting of abnormal results -Policies or lack of systems that create unsafe conditions -Lack of teamwork or coordination of care -Lack of supervision -Expert unavailable
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Error Reduction Techniques: Be Part of the System that Catches Errors
ARCC if you have any concern Ask a question Request a change “I have a concern” Invoke the chain of command
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Error Reduction Techniques: Be Part of the System that Prevents Errors
Patient Care Handoffs (sign outs) Use standard format Regularly review (grade) your sign outs using standardized review form Ask questions For critical test results needing follow-up, use direct communication and build in back-up (have both attending and resident or senior and junior resident follow up)
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