medical errors

1. MEDICAL ERRORS BY ROBERT SAIZI (Dip, BSc )

2. INTRODUCTION Health care is not usually safe as it is intended to be. Everyday many people get injured and die in hospitals silently as a result of preventable medical error In 1999, IOM published a landmark report “To err is human”

3. Intro cont.. 44000-98000 death/year in US Estimated 275 death/day ME affect 1 in every 10 patients worldwide Example: A mix up of results in lab: a client who is HIV- is issued HIV+ positive result.

4. Other examples.. Wrong treatment Incorrect dosage Incorrect route Delay in treatment

5. Intro cont.. Patients have right to safe and effective care at all times H/W have legal obligation to provide safe care Eg . Nonmaleficience and beneficence.

6. Incidence Bangladesh- 75.3% of U/5 with acute diarrhoes received inappropriate treatment ( Alam et al 1998) Nigeria- outpatients prescription common errors- 38% overdosage , 18% underdosage ( Oshikoya & Ojo , 2007) Malaysia- common types of drug administration errors- incorrect time 34%, followed by incorrect technique of administration 22% (Chua et al 2009)

7. Incidence cont.. Malawi- 29% of uncomplicated malaria were subjected to ME ( Osterholt et al 2006)

8. MEDICAL ERROR is.. A failure of planned action to be completed as intended or Use of the wrong plan to achieve an intended aim

9. ADVERSE EVENT Injury caused by medical management rather than the underlying condition of the patient NEGLIGENT ADVERSE EVENT The care provided failed to meet the standard of care reasonably expected of an average physician qualified to take care of patients.

10. TYPES OF ERRORS Skill based errors- slips/lapse-when the action made is not what was intended Rule based mistakes- actions that match intentions but do not achieve their intended outcome due to incorrect application of a rule or inadequacy of the plan Knowledge based mistakes- actions which are intended but do not achieve the intended outcome due to knowledge deficits

11. WHY DO WE SLIP/LAPSE Distraction Misattention Fatique Emotions: boredom,fear and anxiety, anger Environment: noise and heat

12. SLIPS- EXAMPLE Order : 25mg IV diazpam stat Vial says 5mg/ml……5ml vial Brain computes 25mg= 5 vials instead of 5ml Nurse found a 25cc syringe and drew up 125mg

13. What do you REALLY think of this nurse Careless Dangerous Fatiqued

14. SYSTEMS TO REDUCE ERRORS Complexity-too many steps, too many people (communication issues) Workload- too heavy or too light (performance is best when worload is moderate) Poor design- Focus on functionality while ignoring the real life user. Interrruptions and distrations-frequaently associated with errors- 50% in aviation

15. Cont.. Yet extremely common in healthcare- phycians experience 10 interruptions per hour ( chisolm et al 2000) Culture- authority structure impending communication No assignment of responsibility

16. TEST ROW 1 ROW 2 ROW 3

17. WAY TO LEARN FROM ERRORS Incidence reporting-reporting, monitoring and analysing information about adverse events. Root cause analysis- error is inevitable part of human Avoid reliance of memory Use checklist or protocols Always be watchful