2. Patient Safety What is it? Why is it important? What are we doing? What is my part to play?

3. Patient Safety: What Is It? Error -- Failure of a planned action to: be completed as intended or use of a wrong plan to achieve an aim

4. Patient Safety: What Is It Unsafe care can result from: –Fragmented health care system –Faulty systems –Increasing complexity –Lack of awareness of extent of the problem –Culture of individual focus and blame –Lack of systemic view

5. Patient Safety: Why Is It Important? Institute of Medicine report sites studies: –Medical errors occur in 2.9% to 3.7% of hospital admissions. –8.8% to 13.6% of errors lead to death. –Between 44,000 and 98,000 deaths occur each year in hospitals as a result of medical errors.

6. Deaths Due to Preventable Adverse Events in Hospitals Using lower number (44,000), 8th leading cause of death in the United States Exceeding –Motor vehicle accidents (43,458) –Breast Cancer (42,297) –AIDS (16,516) Institute of Medicine report

7. Cost of Medical Errors 459 adverse events identified from 14,732 randomly selected discharges at an estimated health care cost of $348 million. (Not including cost of loss income, disability, etc.) 265 of the 459 adverse events found to be preventable, which represents $159 million in health care cost. Institute of Medicine report

8. Cost of Medication Errors Most do not result in harm but those that do are costly. Recent study: 2% of admissions have a preventable adverse drug event resulting in: –increased LOS of 4.6 days –increased hospital cost of $4,700 / admission –totals $2.8 million for 700-bed teaching hospital. Institute of Medicine report

9. Medications Administered in Allina More than 7 million doses of medications are administered per year in Allina Hospitals and Clinics. Is there an acceptable medication error rate? –A 1% error rate would allow 70,000 errors. –A 0.5% error rate would allow 35,000 errors. –A 0.1% error rate would all 7,000 errors. Our goal is a fail-safe system that is free of errors

10. This Doesn’t Happen Here. Does it?

12. Allina Hospitals and Clinics Patient Safety Vision: Achieve patient care environments free of accidental injury. Patient Safety: What Are We Doing?

13. Safe Delivery Principles Standard processes for doses, dose timing and dose scales Standardized prescription writing Limit number of different kinds of common equipment Implement physician order entry Implement decision support (eg drug dose; drug-allergy) Unit dosing High risk IV supplied only by central pharmacy Written protocols for high risk medications No KCl on care units Pharmacist on rounds Patient information available at point of patient care Allergy wristbands Computer generated MARs Bar coding

14. Hazards Ideal Reality Errors Swiss Cheese Model Defenses Against Errors J. Reason

15. Action: Create a Safety Culture That... understands systems and how errors happen incorporates human factors research expects learning, not blame designs safe systems

16. Action: Allina Patient Medication Safety Task Force Goals: –Increase awareness of unsafe systems. –Implement mechanisms to allow learning from errors. –Establish the principles of safe systems. –Initiate and complete rapid cycle improvements in our systems. –Improve reporting including near misses.

17. Patient Safety - What Is My Part to Play? Practice Principles of Patient Safety Report Identify unsafe systems and take action to protect the patient