Project Objective
Patient Safety for Infants and
Children in Academic Medical
Center Hospitals:
z To
identify human & organizational
factors related to medication events
in infants and children
Organizational and Human Factors
Related to Harmful Medication Event
Outcomes
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1
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Methods
Data Source:
Patient Safety Net™
Net™
z Medication
z
Development history
University HealthSystem Consortium
steering committee of 15 member
organizations April 2001
z
Created Patient Safety Net Goals
error-event data
z 23 Academic medical centers
– Participating in a web based reporting
system
z Years
2001 to 2004
– Standardized taxonomy
– Remove barriers to event reporting
– Real time analysis/management of events
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Key Characteristics of UHC
Patient Safety Net™
Net™
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Population studied
• Easy web based reporting of adverse events,
near misses, unsafe conditions that involve
patients, staff and visitors
Patients from 0 to 18 years
– Infants less that 30 days
– Children from 1 month to 18 years
– Pediatric ICUs , intermediate &
oncology units
– Neonatal ICUs & intermediate units
– Compared to adults over 18 years
• Reports available immediately to managers
• Organizations can compare their data for
benchmarking and identifying areas of
concern
• Integrates current HIPAA regulations
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Patient Safety for Infants and Children i
Academic Medical Center Hospitals:
Organizational and Human Factors Related
to Harmful Medication Event Outcomes
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6
1
Organizational Factor Framework
Organizational & Human Factors
of Reason and Vincent
Conceptual Model
z
z
z
z
z
Rooted in Reason’ organizational accident model.
Complex industrial systems—ID-factors—produce
accidents
ID methods for prevention
ID change of events that lead to adverse events—
errors
Trace back through organizational hierarchy to
staff conditions and context the incident occurred
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•
Patient factors:
•
Task factors
•
Language barrier, disability
• Availability protocols, test results
•
Individual (Staff) Factors
•
Team factors
• Knowledge, skills, and experience
• Communication, Supervision, leadership
7
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Organizational Factors Cont’d
Harm Score
• Work/environmental factors:
– staffing levels, workload
– Maintenance of equipment, building
• Organizational factors:
– Policy standards and goals, Financial constraints
-Medical-legal environment
z Harm
Score: Web input Screen
Patient Safety for Infants and Children i
Academic Medical Center Hospitals:
Organizational and Human Factors Related
to Harmful Medication Event Outcomes
z
Consists of 10 levels of severity
*National Coordinating Council for Medication Error Reporting and Prevention
(NCC MERP) 1998.
9
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Development based on a previous Standardized
Taxonomy of Medication Errors*
– Ranging from ‘unsafe conditions to death
– Levels 1-5: Event does not reach patient ‘ near misses’
– Levels 6-10: Harmful event reaches the patient
• Institutional factors:
-External regulatory bodies
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Factors: Web data screen
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2
Harm Score Distribution for
Adults > 18, Pediatric & Neonatal
Units
Results:
Children in pediatric units had a ‘harmful error’
rate of 5.6% out of a total of 1405 errors
50
Percent harmful errors
Adults: 10.5%
Pediatric units: 5.6 %
Neonatal units: 8.9%
45
40
Infants in Neonatal units had a ‘harmful error’
rate of 8.9% out of a total of 755 errors
Percentage
35
30
25
20
Adults GE 18 N = 20,601
15
Adults over 18 years had a a ‘harmful error’ rate
of 10.5% out of a total of 20,601 errors
Pediatric Units N = 1,405
10
Neonatal Units N = 755
5
0
1
2
3
4
5
6
7
8
9
10
Harm Score
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20.0
13
Medication Errors by
Organizational & Human Factors:
Patients over 18, Pediatric Units, Neonatal Units
14
Factors Significantly Associated with Harm
to Patient
All
pediatric
Adults >=18 patients 1
N=2460
N=24809
Communication
***
***
Distractions/interruptions
***
***
Training issue
*
*
Inexperienced staff
***
***
Staffing insufficient
***
NS
Shift change
*
*
Order entry system prob
***
***
Inadequate resident super
***
***
Emergency situation
***
***
Equipment malfunction
***
NS
Equip availability
NS
NS
No 24 Hr pharm
*
*
***
NS
System for covering pt care
High noise Level
***
***
Cardiac/respiratory arrest
***
***
Pt understanding
***
***
Bed availability
***
***
Pts over 18
Pediatric Units
Neonatal Units
15.0
Percent Errors
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10.0
5.0
D is
t ra C o
ct io mm
ns un
/ in ica
ter tio
I ne T rain rupt n
xp ing ion
erie is s
nc su
Or W o S h e d e
de rk if t s ta
I na r e loa ch f f
de ntry d in ang
qu s y cr e
ate s te ea
s
St resid m pr e
a e o
Ag
en C h ff ing nt s b
c y an in up
, t e ge s u er
mp of ff icie
E m , t s e nt
erg rave rvic
en ler e
cy st
Eq
s it aff
uip
m e F uat io
n lo n
Eq t ma at st
Po
uip lf u aff
lic
n
U n ies/ N o ava ct io
cle pro 24 ilab n
ar ce Hr ilit
po d u ph y
licie res ar
Sy
s /p lac m
st e
m C r roc king
for oss ed
co -co ure
ve ve s
r
St ing p rage
aff t
s c c ar
Lim
he e
d
ite
d a H ulin
cc oli g
es d a
sp y
Ca
rdia H ig Poor t in
F a c/ r h no ligh f o
tig esp is tin
ue ir e L g
/sle at o ev
St ep ry a el
aff de rre
St av a priva st
aff il-a t io
Pa av a tt en n
tie il-- din
n re g
Pt t com side
n
u
La nde plian t
F a ngu rs tan ce
mil age din
yc B g
Be oop arrie
d a era r
v tio
Ob Boa ailab n
s e rde ilit
rva r p y
t io ati
n p en t
at ie
nt
0.0
Pediatic
Units
N=1405
Neonatal
Units
N=755
NS
NS
NS
NS
NS
NS
NS
**
0.03
NS
*
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
*
NS
NS
NS
*
NS
*
NS
NS
NS
NS
NS
Fisher's exact test ***P< .0001,
**P<.01, *P<.05
1
between 1 m o & 18 yrs
Factors
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Observations:
This study provides evidence of specific
human and organizational factors that are
related to medication errors that
necessitate additional treatment, are life
threatening, or result in death.
z
There is some variation in the distribution
of medication errors in children and
infants
Patient Safety for Infants and Children i
Academic Medical Center Hospitals:
Organizational and Human Factors Related
to Harmful Medication Event Outcomes
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Implications for Policy
and Practice
z
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z Identification
of organizational
factors related to harm can be used
to target error-event prevention
programs.
z Provides
evidence to support the use
of standardized web-based event
reporting systems.
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3