Patient Safety Analysis Training: A DoD/AHRQ Partnership

Module 1:
Introduction to Patient Safety Analysis and !ent Manage"ent
"arol! #$ %aplan &arbara abin 'astman
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Module $utline
% Medical rror
& 'ro(ing concerns & Types of e!ents and errors) ter"inology

% Medical !ent Manage"ent

& Sources of e!ent data & !ent reporting syste"s

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$+,ecti!es
Participants (ill +e a+le to:
% -plain ho( studying "edical e!ents can pro!ide infor"ation to i"pro!e patient safety % Define the !arious types of e!ents and errors % -plain the goals and critical ele"ents of an effecti!e e!ent reporting syste" % Descri+e the e!ent "anage"ent process
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'ro(ing Pu+lic /oncern A+out Medical rrors

% Headlines in ne(spapers a+out 0hu"an error1 in hospitals % 2u"erous articles in the "edical literature % 'o!ern"ental attention

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Annual Accidental Deaths

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0To rr is Hu"an1 Institute of Medicine Report 1555

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Report Reco""endations
% sta+lish a national focus of research7 tools7 and protocols to enhance 8no(ledge +ase a+out patient safety

% /reate safety syste"s inside health care organi9ations through i"ple"entation of safe practices at the deli!ery le!el % Identify and learn fro" errors through reporting syste"s : +oth "andatory and !oluntary
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rrors Pro!ide <seful Infor"ation

% =e can learn "ore fro" our failures than fro" success % $ur processes can +e i"pro!ed (hen studied
(Give me a fruitful error anytime, full of seeds, bursting with its own corrections. You can keep your sterile truth to yourself$)
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Types of !ents

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Misad!entures
The e!ent actually happened7 and so"e le!el of har",e!en possi+ly death,occurred?

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2o Har" !ents
The e!ent actually occurred7 +ut no har" (as done?

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2ear Miss !ents

The potential for har" "ay ha!e +een present7 +ut un(anted conse@uences (ere pre!ented +ecause a Areco!eryB action (as ta8en?
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Reco!ery: Planned or <nplanned

% Planned reco!ery
& +uilt into our processes

% <nplanned reco!ery
& luc8y catches

% Study of reco!ery actions is !alua+le?

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Dangerous Situations
An accident waiting to happen

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-ercise:
A patient is ta8en to the $R? The (rist+and is chec8ed7 and it is reali9ed that the (rong patient (as +rought in?
Misadventure? No-harm event? Near miss? Planned recovery? Unplanned recovery?
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-ercise:
A patient is found sitting on the floor of his roo"? He clai"s that he fell? He did not hit his head? He is e-a"ined7 and there are no signs of in,ury?
Misadventure? No-harm event? Near miss? Planned recovery? Unplanned recovery?
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Types of rrors
% Activeerrors co""itted +y those in direct contact (ith the hu"anC syste" interface Dhu"an errorE % Latent delayed conse@uences of technical and organi9ational actions and decisions

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!ents Happen =hen:

latent underlying conditions

+
active hu"an failure

Act ive Erro r

= Event
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Late nt Con ditio ns

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Sharp nd Acti!e Failures

% Indi!iduals at the sharp end are in direct contact (ith the hu"anCsyste" interface
& They ad"inister care to patients & Their actions and decisions "ay result in active failures

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Types of rrors
% Active ( uman! "rrors
& s#ill-$ased & rule-$ased & #no%led&e-$ased

% Gatent rrors Dconditions or failuresE

& technical & organi9ational

% $ther Dpatient related and 0other1E

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S8illCHased rror
Failure in the perfor"ance of a routine tas8 that nor"ally re@uires little conscious effort Example: loc8ing your 8eys in the car +ecause youBre distracted +y so"eone calling your na"e

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RuleCHased rror
Failure to carry out a procedure or protocol correctly7 or choosing the (rong rule Example: not (aiting your turn at a .C(ay stop sign

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Ino(ledgeCHased rror
Failure to 8no( (hat to do in a ne( situation Dpro+le" sol!ing at conscious le!elE Example: not 8no(ing (hat to do (hen the traffic light is out

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RuleCHased !s? S8illCHased rror /ur!e

Knowledge-based Skill-based

Errors

Time
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Hlunt nd Gatent Failures

% Indi!iduals at the $lunt end ta8e actions and/or "a8e decisions that affect technical and organi9ational policies and procedures % These actions and decisions "ay result in latent failures

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Types of rrors
% Acti!e DHu"anE rrors
& s8illC+ased & ruleC+ased & 8no(ledgeC+ased

% Latent "rrors (conditions or failures!

& technical & or&ani'ational

% $ther Dpatient related and 0other1E

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Gatent /ategories Dconditions or failuresE

% Technical
& pro+le"s (ith physical ite"s & e-a"ple: design fla( in soft(are

% $rgani9ational
& pro+le"s resulting fro" decisional ele"ents & e-a"ple C unclear procedure

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Gatent -a"ples
% Technical
& incorrect installation of e@uip"ent & faulty seals on a +lood +ag & for"s that are difficult to use

% $rgani9ational
& decisions "ade +y a regulatory +ody & (ay in (hich ne( staff is oriented & rational "anage"ent decisions that "ay still contri+ute to an e!ent
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!ent -a"ple
% Manage"ent decision to delay co"puteri9ation % Patient read"itted) penicillin allergy % /hart una!aila+le % Patient gi!en penicillin) allergic reaction
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-ercise:
An e-perienced physician is ordering a "edication? She is interrupted +y a telephone call? =hen she gets +ac8 to reading the tu+es7 she has a "ental slip and orders the "ed for the (rong patient? =hat 8ind of "ista8e is thisJ
(echnical? )r&ani'ational? uman?
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-ercise:
A ne( infusion pu"p is introduced in the hospital? The nurse assigned to operate it during the first (ee8 relies on an internal procedure to operate the instru"ent) ho(e!er7 the procedure is inco"plete and lea!es out crucial infor"ation necessary for operation? ? =hat 8ind of "ista8e is thisJ
(echnical? )r&ani'ational? uman?
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The Titanic
A disaster that (as 0set up1K

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Gatent /onditions on Titanic

% Inade@uate nu"+er of life+oats

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Gatent /onditions on Titanic

% 2o trans!erse o!erheads on (ater tight +ul8heads

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Gatent /onditions on Titanic

% 2o 0sha8e do(n1 or practice cruise to train cre(

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Gatent /onditions on Titanic

% 2o training for officers on handling of large single rudder ships

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Gatent /onditions on Titanic

% $nly one radio channel

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rror Data Sources

% % % % % % !ent reporting syste"s Audits Medical records $+ser!ation Patient safety indicators Si"ulation

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!ent Reporting
% % % % To (hat purposeJ =hat are its critical ele"entsJ =hat are the +arriersJ Ho( is the data usedJ

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'oals of !ent AManage"entB

% % % %

Pre!ent failure +ut if you canBt7 Ma8e failure !isi+le and Pre!ent ad!erse effects of failure or Mitigate the ad!erse effects

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Three Ma,or Functions of !ent Reporting Syste"s

% Modeling of ne( or uni@ue e!ents % Monitoring !ents / Ris8s
& type7 /ause7 /hange

% Mindfulness
& a(areness of ha9ards & acti!e engage"ent7 o(nership & feed+ac8 & effect on safety culture
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A Quality !ent Reporting Syste"

% Standardi9e reporting % Pro!ide tools that capture the full co"ple-ity of e!ents in a (ay that is easy to understand % "phasi9e process i"pro!e"ent +ased on "ultiple rather than single e!ents

% /ollect e!ents (ith and (ithout har"7 0nearC "iss1 e!ents7 and 0dangerous situations1
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/o"pliance !s? Adoption

% Mandatory reporting:
& Staff "erely co"ply (hen 0ordered1 to do so

% Loluntary reporting:
& Staff are engaged in patient safety efforts

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Henefits of 2ear Miss !ent Reporting

% Tell us (hy "isad!entures dont happen % Misad!entures are often atypical? 2ear "isses and no har" e!ents gi!e relati!e proportions of classes of syste" failures and help define risk % Raise a(areness of syste" ha9ards % Data Dand lessonsE can +e shared
Chris Johnson, 2001 University of Glasgow
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The !ent Manage"ent Process

*etection +election ,nvesti&ation -lassification . *escription -omputation ,nterpretation
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*etection
Noticin& and /ecordin& the "vent

% Hasic e!ent infor"ation is captured:

& & & & (here and (hen in process type of person in!ol!ed narrati!e description ho( disco!ered

MMDetection rates should +e highMM

& e!ent type/category & contri+uting factors & reco!ery/"itigation stepDsE & etc?

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*etection

HeinreichBs Ratio1
It has been proposed that reporting systems could be evaluated on the proportion of minor to more serious incidents.

% 1 Ma,or in,ury % #5 Minor in,uries % *>> 2oCin,ury accidents

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1. Heinreich HW Industrial Accident Prevention, NY And London 1941

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+election
% If the detection le!el is high7 there (ill +e "any e!ents % !ents "ust +e prioriti9ed as to the type/depth of in!estigation it (ill recei!e

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+election

In!estigation $ptions
% Routine In!estigation
& & & & collect standardi9ed e!ent infor"ation trac8 and Trend inCdepth in!estigation +uild causal tree

% Root /ause Analysis

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+election

Rules for Filtering !ents

% % % % % % % % 2e(7 uni@ue or (orriso"e Pro+a+ility for patient har" Dse!erityE Pro+a+ility of recurrence Potential for organi9ational ris8 Gi8elihood of reco!ery -pert ,udg"ent Detecta+ility /o"+ination of a+o!e
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+election

Tool: Ris8 Matri-

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+election

Tool: 0Fu99y1 Matching

% Si"ilarity function that identifies reports that are "ost si"ilar to a selected or ne( e!ent % If "any si"ilar e!ents are identified7 further in!estigation "ay +e reco""ended
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,nvesti&ation
Conducting a Routine or Expanded Investigation % /ollection of detail on (hat happened at the le!el defined +y the Selection step % Huilding of a causal tree7 if applica+le

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,nvesti&ation

-a"ple of a /ausal Tree

Failure
AN <nit left on infusionC pu"p (ith $ units ) Patient 0iven A 1lood (. *ies!

Reco!ery
2one

Hlood unit not chec8ed for type (hen infused Head nurse distracted

'roup specific +lood ordered in chaotic situation

AN<nit not re"o!ed fro" prior RCcase

AN<nit not re"o!ed (hen $ units hung

'reat confusio n in R

Ine-perience d nurses in R due to stri8e

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S$P in e-tre"e e"ergency inade@uate

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Root /auses

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/lassification O Description
Event classification affects availability of information for learning:
% /lassifications trigger infor"ation processing routines that direct the decision "a8erBs attention

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/lassification O Description

Helie!ing is Seeing
% Pou see (hat you e-pect to see % Pou see (hat you ha!e la+els to see
& classification and e-pectation are 8ey

% Pou see (hat you ha!e the s8ills to "anage % !erything else is a +lur
There lies the developing unexpected event
Weick K, Sutcliffe K, 2001
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/lassification O Description

!ent /oding
% Assign descripti!e e!ent codes +ased on these criteria:
& (here and (hen in the process an e!ent occurred
-a"ple: Phar"acy filled prescription incorrectly

& (here and (hen in the process an e!ent (as disco!ered

-a"ple: Al"ost ad"inistered the (rong "edication
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/lassification O Description

/asual /oding
% -a"ple: The indho!en /lassification Model7 Medical Lersion
& #> codes di!ided into: % latent DTechnical7 $rgani9ationalE % acti!e DHu"anE % other & ai" for *C6 root cause codes for each e!ent7 a "i-ture of acti!e and latent

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/o"putation
Looking at data in aggregate to see patterns and trends
% See patterns or trends in the data % Focus on areas of ris8 % Monitor any changes that ha!e +een i"ple"ented (ithin the organi9ation
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-omputation

Data /an He:

Analy9ed at the local le!el /o"pared to +roadly collected data Dorgani9ational7 national7 international7 standardsCsetting organi9ations etc?E

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-omputation

Types of Data /o"parison and Analysis:

Production of fre@uency distri+ution and trend charts Identification of e!ents "eeting a +road range of para"eters Dcon,uncti!e @ueriesE Si"ilarity "atching

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-omputation

/on,uncti!e Query
% Identification of e!ents "eeting +road range of userCspecified para"eters % Indicates (hich ite"s on the for" to "atch against
& "2ample3 Search for all "edication o"issions disco!ered +y an R2 on a (ee8end
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-omputation

<sefulness of Si"ilarity Matching

% For a AroutineB e!ent7 if there are "any si"ilar e!ents7 do an R/A % For a highCris8 e!ent7 if there are si"ilar e!ents that ha!e already undergone an e-panded in!estigation7 lin8 the cases rather than repeat the R/A

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AG RTQ

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Interpretation
Using data to make measured system changes % /o"putation reports pro!ide infor"ation that identifies the high ris8 areas and trends % In Interpretation7 (e e-plore these areas and trends in search of process i"pro!e"ent opportunities
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DonBt Ta"per

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,nterpretation

Indications of Success
% $!erall ris8 of e!ents (ill decrease o!er ti"e as process i"pro!e"ents are i"ple"ented % Patterns of data (ill change the fre@uency distri+utions of conse@uent7 antecedent7 and causal codes (ill change o!er ti"e
Weick K, Sutcliffe K, 2001
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-a"ples of Analysis Tools

% Root /ause Analysis DR/AE & causal or ris8 trees % Data Mining and /aseCHased Reasoning D/HRE & trend and cluster analysis Failure Mode and ffects Analysis DFM AE Pro+a+ilistic Ris8 Assess"ent DPRAE % SenseCMa8ing
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The !ent Manage"ent Process

*etection +election ,nvesti&ation -lassification . *escription -omputation ,nterpretation
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Su""ary
% Medical rror
& gro(ing concerns & types of e!ents and errors) ter"inology

% Medical !ent Manage"ent

& sources of e!ent data & e!ent reporting syste"s

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An ,ntroduction to Medical "vent /eportin&-Module 4 (han# you

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