130518L - UNDERSTANDING AND LEARNING FROM ERRORS

Lecture for 3^rd year medical students Faculty of Medicine King Fahad Medical City on 18^th May 2013 by Professor Omar Hasan Kasule Sr.

Why is this topic important?

Students and HCW must understand types and causes of errors to be able to prevent them

Errors are a learning experience

Keywords: Error, violation, near miss, hindsight bias, root cause analysis.

Learning objective

·         Understand the nature of error and how health care can learn from error to improve patient safety.

Learning outcomes: knowledge and performance

·         explain the terms error, violation, near miss, hindsight bias.

·         know the ways to learn from errors;

·         participate in an analysis of an adverse event;

·         practice strategies to reduce errors.

Nature of errors

·         In simple terms, an error occurs “when someone is trying to do the right thing, but actually does the wrong thing ie  a non-deliberate deviation from what was intended.

·         Errors may occur by doing the wrong thing (commission) or by failing to do the right thing (omission).

·         Violations are errors caused by a deliberate deviation from an accepted protocol or standard of care.

·         A bad outcome may occur without an error. A error may not be followed by a bad outcome

·         Medical errors are like other errors but medical professionals are reluctant to acknowledge errors because of the culture of ‘infallibility’

·         2 types of error: execution error or lapse (forgetting)

Principal error types

·         Rule-based mistake

·         Knowledge-based mistake

·         Skill-based slips

·         Attention slips

·         Lapses of memory

General error reduction principles

·         Unfamiliarity with the task

·         Inexperience

·         Shortage of time

·         Inadequate checking

·         Poor procedures

·         Limited memory capacity

·         Fatigue

·         Stress, hunger, illness

·         Language or cultural factors

·         Hazardous attitudes

Menmonics to remember the principles: HALT

·         H Hungry

·         A Angry

·         L Late

·         or

·         T Tired

Another mnemonic is IM SAFE

·         I Illness

·         M Medication (prescription alcohol and others)

·         S Stress

·         A Alcohol

·         F Fatigue

·         E Emotion

Incident reporting

·         Incident reporting and monitoring involves collecting and analyzing information about any event

·         An incident-reporting system is a fundamental component of an organization’s ability to learn from error.

·         Incidents are traditionally under-reported, often because the person approach to incident analysis

·         The frequency of reporting and the manner in which incidents are analyzed—using a systems approach rather than a person approach—are heavily dependent on the leadership and “culture”within an organization.

Successful strategies in terms of incident

·         anonymous reporting;

·         timely feedback;

·         open acknowledgement of successes resulting from incident reporting;

·         reporting of near misses is useful in that “free lessons” can be learnt, i.e. system

·         improvements can be instituted as a result of the investigation but at no cost to a patient.

Root cause analysis 1

·         Root cause analysis is a tool to evaluate, analyze and develop system improvements for the most serious adverse events [9].

·         Reporting an incident requires the following basic information: What happened? Who was involved? When did it happen? Where did it happen? The severity of the actual or potential harm. The likelihood of recurrence. The consequences.

·         Root cause analysis focuses on the system and not the individual worker and assumes that the adverse event causing harm to a patient is a system failure.

·         The severity assessment code is used to triage the reported incidents to ensure those indicating the most serious risk to the organization are dealt with first.

Root cause analysis 2

·         The root cause analysis model focuses on prevention not blame or punishment. Other processes are used when people are required to be accountable for their actions.

·         The focus is on systems level vulnerabilities and not individual performance. The model examines multiple factors such as communication, training, fatigue, scheduling,

·         rostering, environment, equipment, rules, policies and barriers.

·         The defining characteristics of root cause analysis include: review by an interprofessional team knowledgeable about the processes involved in the event;analysis of systems and processes rather than individual performance; deep analysis using “what” and “why” probes until all aspects of the process are reviewed and contributing factors are considered;identification of potential improvements that could be made in systems or processes to improve performance and reduce the likelihood of such adverse events or close calls in the future.

Some personal error reduction strategies for students are to

·         know yourself (eat well, sleep well and look

·         after yourself):

·         know your environment;

·         know your task(s);

·         preparation and planning (What if...);

·         build checks into the routine;

·         ask if you do not know.

·         assume that errors will be made and that they should prepare for them;

·         identify those circumstances most likely to lead to errors;

·         have contingencies in place to cope with problems, interruptions and distractions;

·         always mentally rehearse complex procedures or if it is the first time you are doing an activity involving a patient.

Tips are known to limit the potential errors

·         avoid reliance on memory;

·         simplify processes;

·         standardize common processes and procedures;

·         routinely use checklists;

·         decrease the reliance on vigilance.

Summary

·         Both individual and organizational levels through incident reporting and analysis.

·         Barriers to learning from error include: a blame culture that institutes a person approach to investigation and the phenomenon of hindsight bias.

·         A broadly based system approach is required for organizational learning and the possibility of system change to occur.

·         Root cause analysis is a highly structured system approach to incident analysis that is generally reserved for the most serious patient harm episodes.

CASE STUDY #1

A 21-year-old female has died after being administered vincristine accidentally via a spinal route in error. An inquiry is under way. Vincristine (and other vincaalkaloids) should only be given intravenously via aminibag. Vincristine, a widely used chemotherapeutic agent, should only be administered intravenously, and never by any other route. Many patients receiving IV vincristine also receive other medication via a spinal route as part of their treatment protocol. This has led to errors where vincristine has been administered via a spinal route. Since 1968, this error has been reported in a variety of international settings 55 times. There have been repeated warnings over time and extensive labeling requirements and standards. However, errors related to the accidental administration of vincristine via a spinal route continue to occur.

CASE SUDY #2

A 21-year-old male was being treated for non- Hodgkin’s lymphoma. A syringe containing vincristine for another patient had been accidentally delivered to the patient’s bedside. A physician administered vincristine via a spinal route, believing it was a different medication. The error was not recognized and the patient died three days later.

CASE STUDY #3

A 58-year-old female was being treated for non- Hodgkin’s lymphoma. Vincristine was prepared in a 20 ml syringe and delivered in a package containing two other drugs, including methotrexate. Route of administration was not indicated on the solutions. The intrathecal treatment was administered at noon. The hematologist was particularly busy and requested help from another doctor who had not recently participated in intrathecal procedures. The medication was delivered in the patient’s room. The nurse who assists was not familiar with the intrathecal procedures. The 20 ml syringe with vincristine was passed to the doctor who started to inject it. After administering approximately 2 ml, he noticed the size of the syringe and ceased

administration realizing the error. The patient died approximately 100 days later.

Australia, 2004

CASE STUDY #4

A 28-year-old male with Burkitt’s lymphoma was receiving methotrexate via a spinal route. The doctor documented that “vincristine and methotrexate [were] given intrathecally as requested”. The warning label on the vincristine was incomplete, and in small print, being read in a darkened room. The error was not recognized until five days later, after paralysis of the lower limbs had occurred. The patient died after 28 days.

CASE STUDY #5.

As the preoperative team briefing (team discussion before surgical procedure) was coming to an end, a nurse spoke up and reported that “the patient has a left contact lens in his eye”. The anesthetist asked whether it was permanent and the nurse verified that it was disposable. The anesthetist asked the patient why the contact was being worn, but the patient was sedated and not very coherent when he attempted to respond. The nurse explained that the patient was unable to see without the contact. The anesthetist explained to the operating room team that the patient could not have the contact lens with anesthetic and that the patient should not have been sedated with it. One of the team members asked the anesthetist if he wanted the contact lens to be taken out and the anesthetist replied, “Well, he cannot have anesthesia with it”. The surgical resident helped the patient remove the contact lens from his eye. The patient asked for something to put it in so saline was located and the contact lens was stored in a small container of saline.