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Preventing patient errors and promoting medical safety - a guide for medical students

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What medical students need to know about preventing patient errors and promoting medical safety

Publicado en: Salud y medicina
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Preventing patient errors and promoting medical safety - a guide for medical students

  1. 1. The paradox at the heart of medicine •Primum, non nocere – First , Do No Harm •To Err is Human, and errors cause harm !
  2. 2. Why errors are common in hospitals • Not enough time • Complexity • Lack of training • Excessive workload • Bossy seniors
  3. 3. What most of us do in real life when we make or see an error !
  4. 4. Pass the buck
  5. 5. When an error occurs • Patient safety becomes the top priority • All errors , including near misses , should be reported as risk management • Don’t try to hide or cover up !
  6. 6. Problems with reporting • Most errors are not reported • Numbers reported are misleading  Only small percentage detected  Focus on errors of commission ( and not errors of omission)  Medical staff is scared to report  Doesn’t think it’s part of their job to do so  Don’t know whom to report to  Reporting is seen as pointless and time-consuming
  7. 7. Systems, Not People • Medical errors are a property of the system as a whole - not just acts of commissions or omissions by the people in the system • Performance improvement requires changing the system, not changing the people – Sadly, doctors are held to an unattainable standard—perfection
  8. 8. Make the system safer ! ASSSST • Automate ,when possible • Standardize – reduce reliance on memory. Use checklists & standard operating procedures (SOPs) • Simplify . Reduce the number of steps and handoffs • Stress-test the system, to find out the “failure points” so these can be reduced and removed • Safety-Net. Add redundancy (double checks) for high- risk processes • Improve teamwork and communication
  9. 9. Breeding ground for errors !
  10. 10. The second victim of medical errors - doctors
  11. 11. What happens to Doctors when errors occur ! • Blame and Shame • Find a scapegoat !
  12. 12. A doctor’s feelings when he errs! Because he feels responsible • Self-blame • Fear • Guilt • Shame • Anger • Embarrassment • Depression • Humiliation
  13. 13. A doctor’s feelings when he errs! Long term • Frustration • Isolation • Flashbacks and Replays • Nightmares and Sleepless Nights • Grief • Loss of Confidence • Denial, Discounting, Distancing • Taught to be clinically detached and not to feel • Hard to ask for help
  14. 14. How to cope after an error • Be kind to yourself ! • Be kind to each other. Don’t be judgmental • No one is perfect – To Err is Human ! • You aren’t a bad doctor just because you made an error ! • Failure is inevitable, because life has a 100% mortality rate • Healing needs Forgiveness, Support, Recovery and Resilience
  15. 15. Learning to be resilient
  16. 16. HELP – Health Education Library for People Free library at Bombay Central
  17. 17. Positive Safety Culture • Open Culture. Don’t ask who is responsible, ask what is responsible • Just Culture. Restorative justice vs punishment • Reporting Culture. • Learning Culture. Go from backward to forward- looking accountability, to prevent future problems • Promote effective team functioning • Anticipate the unexpected • Design for recovery
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  19. 19. Errors are systemic
  20. 20. Accountability in Systems • A system-based approach to error reduction does not diminish accountability • It directs it in a productive and useful manner, to reduce future errors • Blame is the enemy of safety !
  21. 21. Health IT as a safeguard • EMRs( Electronic Medical Records) and HIS ( Hospital Information Systems) can help reduce medical errors by using artificial intelligence . • Automatic alerts can be triggered when there is a possible toxic drug interaction
  22. 22. DrugHealth Alert Sample via HIS
  23. 23. Medication reconciliation • When patient is shifted from ICU to ward – increased scope for errors • Bar codes as safety nets
  24. 24. Problems with Health IT • Trying to do too many things simultaneously causes errors ! • Inattentional blindness (focusing so much on one thing that you miss another). • Alarm fatigue
  25. 25. Reducing IV Medication Errors • Incidence of errors with injectable medications is higher than with other forms of medications • Half of all harmful medication errors originate during drug administration step Taxis K, Barber N. Ethnographic study of the incidence and severity of intravenous medicine errors. Br Med J. 2003;326:684-7. Cousins DH, Sabatier B, Begue D, et al. Medication errors in intravenous medicine preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care. 2005;14:190-5. Bates D, Spell N, Cullen DJ, et al. The cost of adverse events in hospitalized patients. JAMA. 1997;227:307-11. Bates DW, Cullen DJ, Laird N. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274(1):29-34.
  26. 26. Infusion systems provide a unique protection against medication errors The many available options differ in the respective complexity and number of steps required to prepare the solutions and in the opportunities for potential contamination Ready to useReady to mixManual admixture Open containers Closed containers Ready to useReady to mixManual admixture Open containers Closed containers B RISK Med. Error Risk HIGH LOW
  27. 27. Reducing errors
  28. 28. Hospitals are high complexity zones
  29. 29. The best technology to prevent errors !
  30. 30. Humans as heroes • Humans cause problems – but they are the solution as well ! • Inspite of the chaos and constraints under which hospitals function, the staff still delivers safe care to their patients most of the time. • Their adaptability, foresight and resilience is a shield against errors.
  31. 31. Humans as heroes • Doctors and nurses are the real-life experts • Entropy - natural tendency for things to go wrong. • Safety is a dynamic non-event. • Hard work to achieve this
  32. 32. How to BE SAFE ! • B = Beware = Be aware that errors can happen • E = Education • S= Speak Up • A = Act • F = Facts • E = Error Free. • This a joint effort !
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  34. 34. LASA – Look Alike Sound Alike • Confusing drug names is one of the most common causes of medication error • Contributing factors are – illegible handwriting, – incomplete knowledge of drug names – newly available products, – similar packaging or labelling – similar clinical use – Similar strengths, dosage forms 40
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  36. 36. Role of doctors • Specify dosage form, drug strength & complete directions on prescriptions • Double-check doses and brand names • Use both brand name & generic name on prescription • Legible handwriting in CAPS • Learn good habits now ! 42
  37. 37. Role of the nurse and the patient • Defence against medical errors – safety nets • Nurses have tons of experience and can be great teachers • Listen to your patients !
  38. 38. Sadly, today the clinical staff’s skills are wasted on paperwork
  39. 39. So what’s the solution ?
  40. 40. How can we get doctors to innovate ?
  41. 41. Reinventing Medical Education • We need to teach the next generation of doctors to think out of the box. • Young , intelligent, technically-savvy medical students need to come up with innovative solutions , which allow them to take care of patients on a much larger scale than doctors did in the past.
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