You are Yale-New Haven:
Safety, Errors and You
Robert L Fogerty, MD, MPH
SLIDE 0
Outline
• Scope of the problem
– Macro level
– Micro level
• Yale-New Haven data
• When errors occur
– Disclosure and reporting
– Root cause analysis
– Swiss Cheese model
• Corrective actions
– Pronovost & Semmelweis
– Special Guest
SLIDE 1
Scope of Problem
• To Err is Human: Building a Safer Health System (IOM, 1999).
– 44,000-98,000 people die each year from preventable medical errors.
• 71,000 deaths from Diabetes (2007 CDC)
• 74,000 deaths from Alzheimer’s (2007 CDC)
• 35,000 deaths from Septicemia (2007 CDC)
• If included on death certificates, medical errors would rank in top
10, as high as sixth.
SLIDE 2
SLIDE 3
Scope of Problem
• Err
– Medical Errors costs in US: $17 - $29Billion / year
– Workplace deaths: 6000/year. Medication error deaths: 7,000/year
– More people die from Medical Errors than:
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Breast Cancer (41,000) (2007 CDC)
Emphysema (13,000) (2007 CDC)
Kidney Diseases (46,000) (2007 CDC)
Homicide, Birth Defects, Asthma, Cervical Cancer, HIV COMBINED
(approx. 46,000 total)
SLIDE 4
SLIDE 5
Scope of Problem
• 2007: Wrong side brain surgery – three times.
– Brown
• 2003: Heart/Lung transplant, incompatible blood types (Donor A,
Recipient O).
– Duke
• 2006: Patient paralyzed but not anesthetized for exploratory
laparotomy. Alert and oriented for first 16 minutes of surgery.
– Patient committed suicide two weeks later
SLIDE 6
Gossypiboma
• Retained sponge/towel following surgery
• Yes, it has an actual, formal name
• And an ICD-9 code (998.4)
SLIDE 7
Outline
• Scope of the problem
– Macro level
– Micro level
• Yale-New Haven data
• When errors occur
– Disclosure and reporting
– Root cause analysis
– Swiss Cheese model
• Corrective actions
– Pronovost & Semmelweis
– Special Guest
SLIDE 8
But, I am Yale-New Haven
US Department of Health and Human Services, http://www.hospitalcompare.hhs.gov/. Accessed Jan
12, 2012.
SLIDE 9
Yale-New Haven Errors
• 6 year old patient here for elective hernia repair.
– Wrong side surgery
• LP performed, samples not labeled.
– Need to repeat procedure
• Wrong side chest tube.
• Wrong side thoracentesis.
• Retained surgical sponge/instruments.
– 3-4 times annually.
S L I D E 10
Outline
• Scope of the problem
– Macro level
– Micro level
• Yale-New Haven data
• When errors occur
– Disclosure and reporting
– Root cause analysis
– Swiss Cheese model
• Corrective actions
– Pronovost & Semmelweis
– Special Guest
S L I D E 11
When Errors Occur
• Foolish, arrogant and dangerous to believe you will never commit
an error.
• You have an ethical and professional DUTY to recognize the error.
– Personal improvement
– Prevention of repeating error
– Others can learn
• Disclose, Disclose, Disclose.
– Mandated by Joint Commission.
– AMA guidelines.
– Endorsed by Legal and Risk Services here at YNHH
• 688-2291
S L I D E 12
• Rosner et al (Arch Int Med, 2000)
• “Medical errors occur and are sometimes unavoidable. Physicians
generally, but not always, have ethical and moral obligations to
disclose their errors to the patient. Because common medical errors
can be expected, physicians are obligated to work within health
systems toward reducing systems flaws that promote errors.
However, the obligations of physicians to disclose errors made by
others are less clear.”
S L I D E 13
Root Cause Analysis
• Structured investigation into events.
• Goal is to define the origin of the event.
• No single methodology.
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Multiple viewpoints (interdisciplinary)
Thorough
Repeated
Establish a sequence of events
S L I D E 14
Making a Diagnosis
• Very similar process to a RCA
• Patient with a fever
• Dx: Fever
– What causes fever?
• IL-1
– Innate Immune System stimulation
• Infection
• Leukemia/lymphoma
• Clot
• Exposure
• Drugs
– More background needed.
• History, physical, laboratory assessment, radiographic assessment
S L I D E 15
Making a Diagnosis
• PEX:
– Palpable nodes.
• History:
– 30lbs weight loss, unintentional
• Dx: Cancer
– Is there more than one cancer?
• Lymph node biopsy
– Hodgkin’s lymphoma
S L I D E 16
RCA
• Starts with event
– Patient fall on 10-7.
• What immediately preceded the fall?
– Pt out of bed, unknown to floor staff.
• Should patient have been out of bed?
– Was on fall precautions, ruby slippers and bed alarm.
• Were these measures active?
– Pt wearing ruby slippers. Fall precautions active. Bed alarm off.
• Why was bed alarm off?
– Pt had procedure. Medical staff deactivated bed alarm for procedure
and did not reactivate.
S L I D E 17
Timeline
• Patient fall.
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Procedure performed, requiring deactivation of bed alarm.
Bed alarm not reactivated.
Patient attempted to ambulate.
Fall.
• Corrective action.
– Educate on bed alarm use.
S L I D E 18
Swiss Cheese Model
• James Reason, 1990
Image:
Duke University, DCFM.
S L I D E 19
Types of Errors
• Ineffective Hand offs
– Signout, ED to floor, OR to PACU
• Latent Errors
– “That’s just asking for a problem”
• Heparin in different concentrations, nearly identical vials
• Active Errors
– Incorrectly applying ECG leads
• Knowledge Errors
– Not recognizing or acting on data
S L I D E 20
Location of Error
• Healthcare specific
– Blunt end vs Sharp end.
• Blunt end:
– All the support and ancillary services that surround the patientprovider interaction
• Pharmacy, Shipping and Receiving, the power company, device
manufacturers, pharma.
• Sharp end:
– Refers to sharp end of the scalpel
• MDs, LIPs, technicians, nursing, PT, OT, RT.
S L I D E 21
Outline
• Scope of the problem
– Macro level
– Micro level
• Yale-New Haven data
• When errors occur
– Disclosure and reporting
– Root cause analysis
– Swiss Cheese model
• Corrective actions
– Pronovost & Semmelweis
– Special Guest
S L I D E 22
Systems Engineering
• Did you ever wonder why the Oxygen, Medical Air and Vacuum
wall adapters are different shapes?
– Adverse event. Ventilator connected to nitrous rather than oxygen in
an OR via wall adapter.
– Now that the adapters are, different shapes, it is impossible to put a
green oxygen tree into a non-oxygen wall adapter.
S L I D E 23
Peter Pronovost
• CVC checklist
– 18 month period in Michigan
• Saved $100 million
• Saved 1500 Lives
• N. Engl. J. Med. 355 (26): 2725–32
S L I D E 24
CVC checklist
• Doctors should:
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Wash their hands with soap.
Clean the patient’s skin with chlorhexidine antiseptic.
Put sterile drapes over the entire patient.
Wear a sterile mask, hat, gown and gloves.
Put a sterile dressing over the catheter site.
S L I D E 25
Peter Pronovost
• “The fundamental problem with the quality of American medicine
is that we’ve failed to view delivery of health care as a science. The
tasks of medical science fall into three buckets. One is
understanding disease biology. One is finding effective therapies.
And one is ensuring those therapies are delivered effectively. That
third bucket has been almost totally ignored by research funders,
government, and academia. It’s viewed as the art of medicine.
That’s a mistake, a huge mistake. And from a taxpayer’s perspective
it’s outrageous.”
S L I D E 26
Ignaz Semmelweis
• Father of clean hands.
• “Savior of Mothers.”
– Reduced mortality from 10-30% to 1%.
– Only intervention: Washing of hands.
– Died from sepsis at age 47.
S L I D E 27
Are you the next Semmelweis or Pronovost?
• Patient errors and near misses happen at every hospital in the
world. Yale is no different.
• We are presented with an opportunity to make Yale-New Haven
Hospital and the Yale School of Medicine a beacon for patient
safety.
– Magnet Status
– EMR
– Safe patient flow
• Medical errors are an opportunity to improve.
• Seize the opportunity.
S L I D E 28
Look, if you had one shot, or one opportunity
To seize everything you ever wanted in one moment
Would you capture it or just let it slip?
Marshall Bruce Mathers III
S L I D E 29
Your mission, should you choose to accept it…
• Actually, it is not a choice.
• Your assignment:
– Follow you teams patients closely. Any unexpected death, bad
outcome, readmission, identified error – record the name and MR
number.
– Patient must be in Epic and the details of the event must also be in
Epic
– Bring this case to a session at the end of the clerkship for a real time
Morbidity and Mortality session.
– Blame free environment.
S L I D E 30