1. Error Recognition, Reporting, and Reduction
2013 Yvonne Murphy, MD
Associate Program Director Director of Behavioral Science MacNeal Family Medicine Residency

2. 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

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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)

9. 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

10. Add Descriptions of Your Hospital’s Safety Programs

11. Reporting Errors
Detail how to report errors in your hospital

12. Error Reduction Techniques:
Specific techniques are shown to reduce chance of error when used regularly

13. 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

14. 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

15. 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)

16. Include data on errors in your hospital if available

17. 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)

18. 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

19. 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

20. 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)