1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 15 Medical Errors: An Ongoing Threat to Quality Health Care

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Definitions Medical error: adverse events that could have been prevented given current state of medical knowledge Medication error: preventable event causing or leading to inappropriate medication use or patient harm –Medication in control of health care professional, patient, or consumer Adverse events: adverse changes in health occurring as a result of treatment –Adverse drug event when medications involved

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Seminal Research and Medical Errors Benchmark study by Brennan et al., 1991 Study by Thomas et al., 1999 Study by Van Den Bos et al., 2011

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Seminal Research and Medical Errors (cont.) “To Err Is Human” by the Institute of Medicine (IOM) –Death due to medical errors: possibly eighth leading cause of death in 1999 –More people dying yearly from medical errors than from motor vehicle accidents, breast cancer, or AIDS –Examination of types of errors: adverse events with pharmaceutical agents (potentially preventable) Studies confirming IOM figures Confirmation of scope of medical errors in follow-up report by IOM (2006): “Preventing Medication Errors”

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Seminal Research and Medical Errors (cont.) IOM recommendations: –National goal to reduce medical errors by 50% over 5 years –Four-pronged approach to reducing medical mistakes nationwide (see Box 15.1) National focus Identification of, learning from errors Elevation of standards, expectations for improvement Implementation of safe practices

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Adverse events result from treatment.

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Adverse events are defined as adverse changes in health that occur as a result of treatment.

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Work to Achieve IOM Goals Quality Interagency Coordination Task Force (1998) –Coordination of federal agencies providing health care services –Evaluation of IOM recommendations –Development of strategies for identifying threats to patient safety, reducing medical errors –Final report delivered in February 2000

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Work to Achieve IOM Goals (cont.) National Forum for Health Care Quality Measurement and Reporting (2000) –Also known as National Quality Forum (NQF) –Broad-based, private, not-for-profit body to establish standard quality measurement tools –27 serious reportable events; expanding to 28 events in 2006 and to 29 events in 2011 –National Priorities Partnership (see Box 15.3) –Consensus-based entity for implementing the Affordable Care Act

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Work to Achieve IOM Goals (cont.) Floyd D. Spence National Defense Authorization Act of 2001 –Centralized process for reporting, compiling, analyzing errors Creation of Patient Safety Center The National Patient Safety Foundation (see Box 15.4)

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Work to Achieve IOM Goals (cont.) The Joint Commission –National Patient Safety Goals (first implemented in 2003; see Box 15.5 for 2011 Goals) –Comprehensive database of sentinel events –Root cause analysis; Sentinel Events Policy –Failure mode and effects analysis (FMEA)

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Work to Achieve IOM Goals (cont.) Centers for Medicare and Medicaid Services (formerly HCFA) –Medicare Quality Initiatives –Pay for Performance (quality-based purchasing) –Physician Quality Reporting Initiative; became Physician Quality Reporting System with passage of Affordable Care Act of 2011 –Medicare Improvements for Patients and Providers Act (2008) –“Never events” (see Box 15.6)

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Work to Achieve IOM Goals (cont.) Institute for Healthcare Improvement –Highlighting of evidence-based best practices –Disciplined research and development processes, prototyping projects –Facilitation of further research, adaptation, and adoption of quality improvement strategies Healthcare Report Cards

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The National Priorities Partnership evolved out of which of the following? A. Quality Interagency Coordination Task Force B. Centers for Medicare and Medicaid Services C. National Forum for Health Care Quality Measurement and Reporting D. The Floyd D. Spence National Defense Authorization Act of 2001

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. The National Priorities Partnership developed from the work of the National Forum for Health Care Quality Measurement and Reporting.

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Contemporary Research and Medical Errors HealthGrades (2008) Garrouste-Orgeas et al. (2010) Classen et al. (2011) Landrigan et al. (2010)

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Culture of Safety Management Patient safety: one of nation’s most pressing challenges Mandate for every health care organization IOM final recommendation: implementation of safe practices at delivery level

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Six Sigma Approach Culture of safety management at institutional level Sigma: statistical measurement reflecting product or process performance Higher sigma values = better performance Historically, health care aiming for three sigma processes instead of six

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mandatory Reporting of Errors Mandatory reporting system for medical errors, adverse events at national, state levels At least 27 states requiring hospitals and/or other medical facilities to report serious medical errors 17 states with mandates that pharmacies implement continuous quality improvement Need for increased mandatory reporting at institutional level and by individual providers Possible fear of legal suits or disciplinary measures as barrier for greater disclosure and reporting

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Legal Liability and Medical Error Reporting Medical liability system + litigious society: potential barriers to systematic efforts to uncover, learn from mistakes –Patient Safety Improvement Act (2002) –Patient Safety and Quality Improvement Act of 2005 –Proposed federal legislation to protect voluntary reporting of ordinary injuries, “near misses”

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Leapfrog Group Need for implementation of evidence-based standards such as: –Computerized physician (or prescriber) order entry (CPOE) –Evidence-based hospital referral (EHR) –Intensive-care-unit physician staffing (IPS)

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? A sigma value of three indicates lower performance than a sigma value of five.

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. A sigma value is a statistical measurement that reflects performance. Thus, the higher the sigma value, the better the performance.

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Bar Coding Medications Reduction in point-of-care medication errors National drug code number for all prescription, OTC meds used in hospitals Bar coding + CPOE = increased ability to follow “five rights” of medication admin

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Changing Organizational Culture Quality and Safety Education for Nurses (QSEN) project –Knowledge, skills, and attitudes (KSA) necessary to continuously improve the quality and safety of the health care system –KSA—better able to identify potential errors and intervene before errors occur Organizational cultures needing to remove blame from individual and focus on how organization can be modified to reduce likelihood of errors “Just culture”

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Safety Solutions Look-alike, sound-alike med names Patient identification Communication during patient hand overs Performance of correct procedure at correct body site Control of concentrated electrolyte solutions

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Safety Solutions (cont.) Medication accuracy at transitions in care Avoidance of catheter and tubing misconnections Single use of injection devices Improved hand hygiene to prevent health care– associated infections

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would most likely be most significant in promoting a culture of safety management? A. Mandatory reporting of errors B. Six sigma approach C. Bar coding meds D. Removal of blame

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Although mandatory reporting of errors, a six sigma approach, and bar coding meds are important in promoting a culture of safety management, perhaps the most significant change that must occur is that organizational cultures must be created that remove blame from the individual and focus on how the organization can be modified to reduce the likelihood of errors occurring in the future.

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins End of Presentation