Beruflich Dokumente
Kultur Dokumente
Man goes into cardiac arrest at Cupka's bar, in the South Side
Prevalence
Average of 1.7 mistakes per patient per day in ICU (out of 200 patient-care activities)
1% failure rate is too high to be tolerated
At 99.9%, there would be two unsafe plane landings at OHare airport each day, U.S. postoffice would lose 16,000 pieces of mail, and 32,000 bank checks would be deducted from wrong accounts every hour
From Lucien Leape
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Patient Safety
The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the processes of health care. These events include "errors," "deviations," and "accidents." Safety emerges from the interaction of the components of the system; it does not reside in a person, device or department. (Cooper, et al)
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Patient Safety
Freedom from accidental injury establishment of operational systems and processes that
minimize the likelihood of errors maximize the likelihood of intercepting them when they occur. (Kohn)
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Patient Safety
actions undertaken by
individuals organizations
to protect health care recipients from being harmed by the effects of health care services.
(Spath)
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Medical Error
Medical Errors
Adverse Event
AE
Injury that results from medical care, not a part of the natural disease process
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Adverse Events
Non-preventable Adverse Events
AE
Medical Errors
Near Miss
Near MissPotential Medical Error Intercepted error
Medical Errors
Near Miss
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Medical Errors AE
Near Miss
Preventable AE
DANGER
Hazards
Defenses can be hardware (e.g., monitors), people (e.g., nurses) or administrative (e.g., acceptable protocols)
(From Managing the Risks of Organizational Accidents, Reason, 1997)
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A Near Miss
Defenses
DANGER
Hazards
Usually several defenses must fail to cause an accident Just one remaining intact is enough to prevent a near-miss becoming an accident
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A Harmful Event
Defenses
DANGER
Hazards
Adverse Event
What is the cause? The hazard? Failure of which defense? This is the problem with assigning single causes Blame/cause often is assigned to the last barrier [usually a person] to fail!!
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Quality and
Error
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To Err is Human
Process People
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To Err is Human
Process 85% People..15%
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Hazards
Adverse Event
Lab tech Result to office nurse Patient Falls Cerebral Hemorrhage Physician interprets Patient contacted
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Errors
Most organizational errors are made by well-intentioned human beingsmost highly educated, well trained, well intentioned human beingswho become accustomed to small glitches, routine foulups, and a culture that suppresses doing much about them in the name of an overriding goal.
James Reason Internal Bleeding
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Latent Errors
Latent errors = process or system failures
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Presented at the: 33rd NAPCRG Annual Meeting October 15-18, 2005 Quebec City, Quebec, Canada
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Context
Primary Care:
~ a billion office visits annually the medical home for most Americans Malpractice claims = burden of serious harms and death from medical errors is substantial Most studies of errors reported by physicians = important but limited lens
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Setting
10 family physician offices:
5 private practices 5 residency clinics
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Asked to Report
That should not have happened and that you dont want to happen again Small or large, administrative or clinical Could be events or processes that didnt happen but should have happened
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Results
401 physicians and staff signed a consent form and/or participated in site training (86% of eligible) Clinic physicians, NPs/PAs, residents, and staff reported 726 events, 717 with errors
Staff 384 (53%) physicians 278 (38%) residents 46 (6%) NPs and PAs 18 (3%)
66 62 17 37 37 21 35 20 14 18
109 42 77 57 26 37 10 17 13 3
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Multiple errors
Multiple errors:
4 reports contained four errors 33 reports contained three errors 183 cases two errors
93 cascades
Chart completeness and availability; medications; appointments; laboratory; patient flow; and filing systems.
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Seriousness
Complex patients more likely very/extremely serious harm (31% vs. 20%, p=0.013) No difference in risk for patients with chronic conditions (29% vs. 21%, p=0.086) No differences for patients familiar vs. unfamiliar
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Non-serious 42%
Preventable 12%
Ameliorable 31%
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143 8 % 62
1 15 46
3%
2% 24% 74%
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57 % are NOT SATISFIED with the way they manage test results
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33% of women with abnormal mamograms or PAP smears do not receive appropriate follow-up care
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5. Make sure you understand what will happen if you need surgery.
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SUMMARY
Medical error and near-misses occur both in hospital and ambulatory settings Medical error is typically the result of process problems