To Err Is Human Building a Safer Health System (2000) / Chapter Skim
Currently Skimming:
Pages 155-204
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 155... ...
vrs.1 C atety systems in health care organizations seek to prevent harm to _ patients, their families and friends, health care professionals, con_ tract-service workers, volunteers, and the many other individuals whose activities bring them into a health care setting. Safety is one aspect of quality, where quality includes not only avoiding preventable harm, but also making appropriate care available providing effective services to those who could benefit from them and not providing ineffective or harmful services.2 As defined in Chapter 3, patient safety is freedom from accidental injury.
|
From page 156... ...
RECOMMENDATIONS The committee is convinced that there are numerous actions based on both good evidence and principles of safe design that health care organizations can take now or as soon as possible to substantially improve patient safety. Specifically, the committee makes two overarching recommendations: the first concerns leadership and the creation of safety systems in health care settings; the second concerns the implementation of known medication safety practices.
|
From page 157... ...
Safety is an emergent property of systems. In order for this property to arise, health care organizations must develop a systems orientation to patient safety, rather than an orientation that finds and attaches blame to individuals.
|
From page 158... ...
This report calls on organizations and on individual practitioners to address patient safety. Health care is composed of a large set of interacting systems paramedic, emergency, ambulatory, inpatient care, and home health care; testing and imaging laboratories; pharmacies; and so forth that are connected in loosely coupled but intricate networks of individuals, teams, procedures, regulations, communications, equipment, and devices that function with diffused management in a variable and uncertain environment.5 Physicians in community practice may be so tenuously connected that they do not even
|
From page 159... ...
They also bring characteristics that are common to everyone, including difficulty recalling material and making occasional errors. Safety Systems in High-Risk Industries The experience in three high-risk industries chemical and material manufacturing and defense provides examples of the information and systems that can contribute to improved safety and of the safety achievements that are possible.
|
From page 160... ...
U.S. Navy: Aircraft Carriers People are quick to point out that health care is very different from a manufacturing process, mostly because of the huge variability in patients and circumstances, the need to adapt processes quickly, the rapidly changing knowledge base, and the importance of highly trained professionals who must use expert judgment in dynamic settings.
|
From page 161... ...
Weick and Roberts12 have studied peacetime flight operations on aircraft carriers as an example of organizational performance requiring nearly continuous operational reliability despite complex patterns of interrelated activities among many people. These activities cannot be fully mapped out beforehand because of changes in weather (e.g., wind direction and strength)
|
From page 162... ...
Because errors can arise from a lack of direct communication, the ship's control tower communicates directly with each division over multiple channels. As in health care, it is not possible in such dynamic settings to anticipate and write a rule for every circumstance.
|
From page 163... ...
As described in Chapter 3, instances of patient harm are usually attributed to individuals "at the sharp end" who make the visible error. Their prevention, however, requires systems that are designed for safety that is, systems in which the sources of human error have been systematically recog nized and minimized.15 l6 In recent years, students of system design have looked for ways to avoid error using what has been called by Donald Norman17 "user-centered design." This chapter draws on six strategies that Norman outlines.
|
From page 164... ...
Other examples of natural mapping are arranging light switches in the same pattern as lights in a lecture room; arranging knobs to match the arrangement of burners on a stove; or using louder sound, an increasingly brighter indicator light, or a wedge shape to indicate a greater amount. A fourth important strategy is the use of constraints or "forcing functions" to guide the user to the next appropriate action or decision.
|
From page 165... ...
In hospitals, infection control and medication administration are examples of organization-wide systems that encompass externally imposed regulations, institutional policies and procedures, and the actions of individuals who must provide potentially toxic materials at the right time to the right patient. PRINCIPLES FOR THE DESIGN OF SAFETY SYSTEMS IN HEALTH CARE ORGANIZATIONS Hospitals and other institutions have long-standing efforts to ensure patient safety in a variety of areas.
|
From page 166... ...
Recommendation 5.1 calls for mandatory reporting of serious adverse events by health care organizations. Recommendation 7.1 urges regu
|
From page 167... ...
Nevertheless, their participation in the safety efforts of these organizations is crucial. Health care practitioners should seek to affiliate themselves with organizations that embrace such aims, whether the organizations are hospitals, managed care organizations, medical societies, medical practice groups, or other entities.
|
From page 168... ...
, but few have patient safety programs. The committee emphasizes that by health care organizations, it intends such safety programs to be established not only by hospitals, but also by other organizations, including managed care organizations and the delivery sites with which they contract.
|
From page 169... ...
Although these represent a small proportion of health care workers, they are unlikely to be amenable to the kinds of approaches described in detail in this chapter. Registration boards and licensure discipline is appropriately reserved for those rare individuals identified by organizations as a threat to patient safety, whom organizations are already required by state law to report.
|
From page 170... ...
However, human beings also have well-known limitations, including difficulty in attending carefully to several things at once, difficulty in recalling detailed information quickly, ancl generally poor computational ability.21 Respecting human abilities involves recognizing the strengths of human beings as problem solvers, but minimizing reliance on weaker traits. Several strategies are particularly important when considering such human factors: designing jobs for safety; avoiding reliance on memory ancl vigilance; using constraints ancl forcing functions; ancl simplifying ancl standardizing key processes.
|
From page 171... ...
Removal of concentrated potassium chloride from patient floor stock is a (negative) forcing function.25 Less restrictive, but user-oriented approaches to design are the use of affordances and natural mappings.
|
From page 172... ...
Other examples of simplification include limiting the choice of drugs available in the pharmacy, limiting the number of dose strengths, maintaining an inventory of frequently prepared drugs, reducing the number of times per day a drug is administered, keeping a single medication administration record, automating dispensing, and purchasing easy-to-use and maintain equipment.27 Stanc~arc~ize Work Processes Standardization reduces reliance on memory. It also allows newcomers who are unfamiliar with a given process or device to use it safely.
|
From page 173... ...
They may not appreciate each other's strengths or recognize weaknesses except in crises, and they may not have been trained together to use new or well-established technologies. The committee believes that health care organizations should establish team training programs for personnel in critical care areas (e.g., the emergency department, intensive care unit, operating room)
|
From page 174... ...
· Improve access to accurate, timely information. Ac~opt a Proactive Approach: Examine Processes of Care for Threats to Safety anc]
|
From page 175... ...
Indeed, many technologies are engineered not only for safe operation in the care process, but specifically for the purpose of preventing error. Such technologies include automated order entry systems; pharmacy software to alert about drug interactions; and decision support systems such as reminders, alerts, and expert systems.
|
From page 176... ...
A reliable system has procedures and attributes that make errors visible to those working in the system so that they can be corrected before causing harm. Examples of procedures to mitigate injury are · keeping antidotes for high-risk drugs up-to-date and easily accessible; · having procedures in place for responding quickly to adverse events, such that these processes are standardized across units and personnel are provided with drills to familiarize them with the procedures and the actions each person should take; · equipment that defaults to the least harmful mode in a crisis; and .
|
From page 177... ...
It will be a great challenge to develop simulation technology and simulators that will allow full, interdisciplinary teams to practice interpersonal and technical skills in a non-jeopardy environment where they can receive meaningful feedback and reinforcement. Improve Access to Accurate, Timely Information Information about the patient, medications, and other therapies should be available at the point of patient care, whether they are routinely or rarely used.
|
From page 178... ...
; ensure that services are obtained and track outcomes of treatment; and aggregate data from large numbers of patients, both to measure outcomes of treatment; and to promptly recognize complications of new drugs, devices, and treatments.43 The committee also believes that organizations, individually and in collaboration, must commit to using information technology to manage their knowledge bases and processes of care. Doing so will require the integration of systems that are patient specific, allow population-based analyses, and systems that manage the case process through reminder, decision support, and guidance grounded in evidence-based knowledge.
|
From page 179... ...
Attempting to change such a culture to accept error as normal is difficult, and accepting the occurrence of error as an opportunity to learn and improve safety is perhaps even more difficult. As noted at the beginning of this chapter, it requires at a minimum that members of the organization believe that safety is really a priority in their organization, that reporting will really be nonpunitive, and that improving patient safety requires fixing the system, not fixing blame.
|
From page 180... ...
Finally, staff should be given timely feedback on the results and how problems will be addressed.47 Develop a Working Culture in Which Communication Flows Freely Regarc] less of Authority Gradient Organizations also have to foster a management style in dealing with error that supports voluntary reporting and analysis of errors so there are no reprisals and no impediments to information flowing freely against a power gradient.
|
From page 181... ...
The fourth is implementation, and the fifth is tracking the changes to learn what new safety problems may have been introduced. Organizations should develop and maintain an ongoing process for the discovery, clarification, and incorporation of basic principles and innovations for safe design, and should use this knowledge to understand the reasons for hazardous conditions and ways to reduce these vulnerabilities.
|
From page 182... ...
For example, the New England Cardiovascular Project, the Vermont-Oxford Neonatal Network, and multisite research on the organization and delivery of care in intensive care units have demonstrated the gains that are possible from such collaborative work.49 50 The committee strongly encourages organizations to participate in voluntary reporting systems. Chapter 5 provides descriptions of some voluntary reporting systems available in the health care industry, and the committee has recommended that voluntary reporting initiatives be encouraged and expanded.
|
From page 183... ...
· Ensure the availability of pharmaceutical decision support. · Include a pharmacist during rounds of patient care units.
|
From page 184... ...
Prescribers should avoid use of abbreviations Establish processes in which prescribers enter medication orders directly into computer systems Prescribers should move to a direct, computerized order entry system Use unit dose medication The medication order should distribution and pharmacy- include drug name, exact based intravenous medication admixture systems metric weight or concentration, and dosage form Differenti. look-al sound Decrease
|
From page 185... ...
. Cations nove to a ad order r should , exact ncentration' Differentiate: eliminate look-alikes and sound-alikes Decrease multiple entry Standardize drug packaging, labeling, storage Avoid abbreviations Computerize drug order entry Use "unit dose" drug systems (packaged and labeled in standard patient doses)
|
From page 186... ...
186 TABLE S-1 Continuecl TO ERR I5 HUMAN IOM Strategy National Coordinating American Society of Council for Medication Error Health-System Pharmacists Reporting and Prevention Institute Healthca Central pharmacy should supply high-risk intravenous medications Use special procedures and written protocols for the use of high-risk medications Do not store concentrated solutions of hazardous medications on patient care units Ensure the availability of pharmaceutical decision support Include a pharmacist during rounds of patient care units Use protc checkli All medication orders before a first dose should be routinely reviewed by a pharmacist and all staff should seek resolution whenever there is a question of safety Assign pharmacists to work in patient care areas in direct collaboration with prescribers and those administering medications
|
From page 187... ...
Including written guidelines, checklists, pre-printed orders, double-checks, special packaging, special labeling, and education Remove concentrated potassium chloride (KCI) vials from nursing units and patient care areas.
|
From page 188... ...
in their medication- the weight of the patient on use processes the prescription or medication order Adopt a system-oriented Approach medication errorsIncrease 1 approach to medication as system failures and seekteamed error reduction system solutions to preventingobtain themcommi commr Improve patient's knowledge about their treatment Prescription orders should include a brief notation of purpose unless considered inappropriate Prescribers should not use vague instructions such as "Take as directed" as the sole direction for use Develop better systems for monitoring and reporting adverse drug events Improve ~ inform. Organize for safe
|
From page 189... ...
in the medication administration process Encourage the use of computer-generated or electronic medication administration records (MAR) Adopt a systems-oriented approach to medication error reduction; promote a non-punitive atmosphere for reporting of errors which values the sharing of information lot use Improve access to Educate patients Educate patients in the such as information Patients should tell physicians hospital, at discharge, and in as the sole about all medications they ambulatory settings about are taking and ask for the safe and accurate use of information in terms they their medications understand before accepting medications Organize the work environment for safety
|
From page 190... ...
Putting such information in computerized order entry forms can help eliminate such errors. Limit the Number of Different Kin cats of Common Equipment Simplification reducing the number of options is almost as effective as standardization in reducing medication errors.
|
From page 191... ...
. Direct order entry reduces errors at all stages of the medication process, not just in prescribing60 and it has been recommended by National Patient Safety Partnership, a coalition of health care organizations.= One study estimated cost savings attributable to preventable adverse drug events (ADEs)
|
From page 192... ...
Software is available that permits pharmacists to check each new prescription at a minimum for dose, interactions with other medications the patient is taking, and allergies. Although not as sophisticated as computerized physician order entry, until the latter is in place, pharmacy computerized checking can be an efficient way to intercept prescribing errors.
|
From page 193... ...
Unit dosing has been recommended by the American Society of Health-System Pharmacists, ICAHO, NPSF, and the MHA in their "Best Practice Recommendations." As a cost-cutting measure, unfortunately some hospitals have recently returned to bulk dosing, which means that an increase in dosing errors is bound to occur. Have the Central Pharmacy Supply High-Risk Intravenous Medications Having the pharmacy place additives in IV solutions or purchasing them already mixed, rather than having nurses prepare IV solutions on patient care units, reduces the chance of calculation and mixing errors.
|
From page 194... ...
Medication Errors Reporting Program.68 Ensure the Availability of Pharmaceutical Decision Support Because of the immense variety and complexity of medications now available, it is impossible for nurses or doctors to keep up with all of the information required for safe medication use. The pharmacist has become an essential resource in modern hospital practice.
|
From page 195... ...
They found that in one large, urban, teaching hospital the rate of preventable adverse drug events related to prescribing decreased significantly 66 percent from 10.4 per 1,000 patient-days before the intervention to 3.5 after the intervention; the rate in the control group was unchanged. Make Relevant Patient Information Available at the Point of Patient Care Many organizations have implemented ways to make information about patients available at the point of patient care as well as ways to ensure that patients are correctly identified and treated.
|
From page 196... ...
In addition to patients' informing their health care practitioner about their current medications, allergies, and previous adverse drug experiences, the National Patient Safety Partnership has recommended that patients ask the following questions before accepting a newly prescribed medication:75 · Is this the drug my doctor (or other health care provider) ordered?
|
From page 197... ...
SUMMARY This chapter has proposed numerous actions based on both good evidence and principles of safe design that health care organizations could take now or as soon as possible to substantially improve patient safety. These principles include (1)
|
From page 198... ...
"Error Reduction as a Systems Problem," in Human Error in Media: cine, ea., Marilyn Sue Bogner, Hillsdale, N) : Lawrence Erlbaum Associates, 1994.
|
From page 199... ...
"Medical Devices, Medical Errors, and Medical Accidents," in Human Error in Medicine, Marilyn Sue Bogner, ea., Hillsdale, N) : Lawrence Erlbaum Associates, 1994.
|
From page 200... ...
.; Clapp, Margaret D., et al. Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit.
|
From page 201... ...
News Release. National Patient Safety Partnership, May 12, 1999.
|
From page 202... ...
o In Ail .o he ;= o ~ ~3 ~ 3 ~ E ' c S c, 'a ~ ~ =.c~)
|
From page 203... ...
Appendixes
|
From page 204... ...
3 o us v)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.