Introduction to Patient Safety
Nazanin Meshkat MD, FRCP,
MHSc
Lessons from Chernobyl
• Operators continued a planned test despite
multiple indicators that things were going
wrong
• System errors
– A shut down system that was too slow
– An over reliance on operators for system
operation
– A lack of communication
– Poor planning
Safety Critical Industries
• Nuclear plants
• Aviation
• Healthcare
Objectives
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What is an “unsafe act” and error
Understand why errors occur
Human factors engineering
To understand the role of teamwork and
communication in patient safety
Patient Safety
• World Health Organization definition =
"freedom…from unnecessary harm or
potential harm associated with
healthcare”
“To Err Is Human”
• Institute of Medicine 1999
– 44,000 and 98,000 people die each year in
US hospitals due to medical errors
– More than motor vehicle accident deaths in
US
Likely Under-Reported
• Errors are not always recognized when they
occur
• Fear of punishment
• Reporting systems can be cumbersome.
So what?
• Cost to…
– Individual
– Family
– Health care providers
– Healthcare system
• Centers for Medicare and Medicaid
Services (CMS), more than one million
patient safety incidents occurred to
hospitalized Medicare patients in the US
over the years 2002 to 2004, causing
more than 250,000 deaths and costing
$9.3 billion
Why do errors occur?
Lab
Limited
Resources
Pharmacy
Nurse
Anesthetist
Variable
Pt
Volumes
Wards
Drugs
ER Doctor
Resident
New Research, poor knowledge translation
Rapid
Patient
Decisions
High acuity
Medical
Many
Nurse
Student
Distractions
Variability inHandoffs
practice
and interruptions
Intern
Radiology
Department
Consultants
Lab
SYSTEM
Information
flow
Transitions or “handoffs”
• Risky time
– Great deal of information to communicate
– Short amount of time
– Human factors - interruptions, tired
• Information is LOST, FORGOTTEN,
MISCOMMUNICATED
“Dynamic non-event”
• To make "nothing bad happen" requires
a lot of good things to be done right.
We all do unsafe things
• After a night shift, I got into my car to
drive home, and while making a right
turn, I rear-ended another car
Unsafe Acts
• Errors
• Violations
Errors
• Errors classified into two types of failures
– An action goes as intended but it’s the wrong one
= Mistake
– An action does not go as intended = Error of
Execution
• Slip - Action Based
• Lapse - Memory Based (a lapse in memory)
Violations
• “A deliberate deviation from an
operating procedure, standard or rule”
• “Drift” a slow, incremental move away
from safe actions
How do we make decisions…
• Automatic cognition
• Active problem solving
Automatic Cognition
• Concept of heuristics - cognitive
shortcuts that allow for rapid, often
unconscious decision making
• You get up in the morning, brush your
teeth, shower…
Are these lines straight?
Optillusions.com
Automatic Cognition
• Unfortunately, heuristics are also
associated with cognitive biases that
can be strong, but incorrect.
• Errors in Automatic Cognition are
Caused by Errors of Execution (slips
and lapses)
Example of Heuristics
• DO----MINE - dopamine or dobutamine
• HY----ZINE - hydralazine or hydroxyzine
Problem Solving
• Problem-solving is slow, conscious,
sequential
Problem Solving Errors
• Affected by “habits of thinking”
• Cognitive biases
– Memory bias
– Overconfidence
– Confirmation bias
Both Automatic Cognition and
Active Problem Solving
Affected by…
• Internal Factors or endogenous causes
– Psychological states (anger, fear, boredom,
anxiety)
– Physiological states (fatigue, illness)
• External Factors or exogenous causes
– Environmental factors (noise, heat, light), long
work schedules, inadequate training, interruptions
and distractions
Both Automatic Cognition and
Active Problem Solving
Affected by…
• External Factors or exogenous causes
–
–
–
–
Environmental factors (noise, heat, light)
Long work schedules
Inadequate training
Interruptions and distractions
Internal Factors
Peak
Performance
Anxiety
Boredom
Stress Levels
Internal Factors
• Impact performance and personality
negatively
–
–
–
–
–
–
–
Reduce decision-making ability
Prolong response times
Increase lapses in attention
Affect short term memory
Lessen ability to multitask
Increase irritability, moodiness and depression
Decrease ability to communicate
Internal Factors
• After one night of missed sleep - performance
can decrease by 25%
• After 17 hours of being awake, the cognitive
performance among test subjects equivalent
to that of someone who was drunk
• Would you ever consider going to work
drunk? Not likely; but you probably go to work
tired all the time.
Latent Errors vs. Active Errors
• Latent errors are existing defects in the
design and organization of processes
and systems that can lead to failures
and errors
– often unrecognized or just become
accepted aspects of the work
• Lead to active errors, whose effects
are felt immediately
Latent Errors vs. Active Errors
• While the person on the front line - the
doctor, nurse, or pharmacist - might be
the proximal cause of the active
error, the real root causes of the error is
often present within the system for a
long time, as accidents waiting to
happen!
Latent Errors vs. Active Errors
• The process of “Normalization”
– Acceptance of unacceptable processes
How to Prevent Errors
What does not work…
• ”Blame and shame”
• Countermeasures that have become the norm in
medicine include
–
–
–
–
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Creating a sense of fear
Disciplinary measures
Threats of litigation
Retraining (using outdated and ineffective training methods)
Naming, blaming, and shaming.
What works…
• Instead of telling people to be more
careful, you have to change systems
• Can redesign systems using “human
factors principles”
Human Factors Engineering
• Human factors is the study of “the
interrelationship between humans, the tools
and equipment they use in the workplace,
and the environment in which they work.”
• How to design processes that make it easy
for people to do things right
– …and hard to do things wrong.
How do you do that?
• Enhance mental and physiological
states
– Reduce or mitigate fatigue, stress,
dehydration, hunger, boredom, guilt,
feeling undervalued, low moral, anxiety
How do you do that?
• Enhance decision making AND
execution through…Environment
Design
System Redesign
• Change Systems - Processes,
procedures, communication, equipment,
organizational culture
System Redesign
• Change Systems - Processes, procedures,
communication, equipment, organizational culture
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–
–
–
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Simplify
Standardize
Use forcing functions and constraints
Avoid reliance on memory
Use redundancies
Automate
Promote effective team functioning
Simplify
• My niece and
nephew use their
dad’s iPhone all the
time!
• Because it is so
simple to use!!
Simplify
• Make tasks easy to do
– The simpler it is, the less chances an error
will be made
– The more complex - users may “work
around” it (e.g. skips steps)
Simplify
• Make sure that an
item’s purpose is
easily understood by
the user
Standardize
• Eliminate
– Variation
– Confusion
– Complexity
• Enhance
– Uniformity
– Predictability
– Consistency
Examples - Protocols, Pre-Printed Medication Order
Forms, Clinical Care Pathways
Use Forcing Functions and
Constraints
• Constraint makes it
difficult to complete
a task (when indeed
that task should not
be completed)
• E.g Do not keep
high dose
Potassium Chloride
in the medication
cabinet to avoid
accidental
administration to a
patient!
Use Forcing Functions and
Constraints
• Forcing Functions
make it impossible
to do a task
incorrectly
• E.g When you are
about to close up a
document you have
spent 6 hrs preparing
without saving it, the
software prompts you
“Do you want to save
the document?” before
it lets you close the
document
Use Redundancies
• What?? You just said Simplify
• Redundancies, when carefully
planned, can reduce errors in
COMPLEX processes or those that can
lead to significant harm
• Double check
– E.g. When giving blood products have two
nurses read through patient info
Avoid Reliance on Memory
• Human brain can reliably hold only
between five and seven pieces of
information at a time
• Use checklists
– E.g. For administration of certain
medications or blood products
– E.g. During handover
Automate
• …But carefully
• Technology can be expensive, and just because you
use technology, it will not lead to change
– The best technology in a broken system will fail
– Also has the potential to introduce yet another step, which
could lead to more room for error, misinterpretation, increase
workflow
Automate
• In some countries there are Computer
Prescriber Order Entry systems
• Studies found that they led to increased
errors!
Promote Effective Team
Functioning
Team Work
• What makes a
successful Sports
team makes a
successful health
care team!
• Work together
– No matter who you are in
the team
– No matter how “good” you
are, or your level of
expertise
• Value expertise and input
from others
• Communicate
Team Work: Work Together
• Engage all team members
• Encourage Feedback
• Respond constructively to suggestions
Team work: Value Each Other
• Psychological safety
– No blame, no undervaluing, no intimidation
– Respect and value every team member’s
opinions, values, and emotions
– Every team member should be comfortable to
speak up and communicate
– Every team member is treated with respect
Team Work: Communication
• Communication Tools
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–
–
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Multidisciplinary rounds
Briefings e.g. before our simulation cases
Debriefing
SBAR = Situation, Background, Assessment,
Recommendation
– Checklists
– Verbal Repeat backs - Closed loop conversations
Error and Harm
• Not all Error leads to harm (thankfully!)
• …But sometimes it does
Swiss Cheese Model
• Every error is an opportunity to improve
the process
Examples of what has worked
WHO Surgical Safety
Checklist
• A prospective study using the checklist
showed the rate of death declined by
almost 50 percent and the complication
rate decreased by almost 40 percent.
Protocols
• Patient identifiers - and checking them
during medication or blood
administration
• Protocols to decrease surgical site
infections
• Specimen labeling and handling
• Disinfection and sterilization
• Hand washing and sanitation
Other..
• Medication bar coding to prevent medication
errors
• Medical Emergency Teams (Rapid Response
Teams)
– 65% reduction in cardiac arrests and a 24%
reduction in overall patient mortality
• Executive WalkRounds
• Effective Care Plans
– Delineate Responsibilities
– Delineate Timelines
• A patient is having an acute heart attack
when he arrives in the emergency
department. Very rapidly, the team initiates
care - giving medication to reduce the
patient’s pain, giving medications to limit
heart damage, and activating the cardiac
catheterization lab team to quickly perform an
angioplasty. As a result, the patient does quite
well and leaves the hospital three days later
with normal heart function.
Tie into quality improvement
• Implement changes/recommendations
using quality improvement projects
• Prevent an error before it happens
First, do no harm