Scope of the safety problem:
- Safety is an implied minimum standard in providing health care. Yet many are harmed as a result of medical error.
- Research in the area of medication safety & error
prevention has identified some serious concerns for patients & care providers. - As health care delivery systems become more complex, it is evident that the opportunities for error abounds.
▪ The costs of medication-related morbidity & mortality are high.
▪ Many medication errors are preventable, and physicians, nurses, pharmacists can play a vital role in diminishing medication errors.
▪ The medication use process is highly complex, problem-prone, and requires a systematic approach for improvement. - Additional studies frame the issue of medication-related errors in other settings by identifying errors in prescribing and dispensing of prescriptions in an outpatient environment.
- One study found that between 3% and 11% of hospital admissions were attributable to ADEs.
- Errors reoccur despite the best educational and planning efforts.
- To understand what is or is not known about medication-related adverse events, common definitions must be established and understood.
is a complex process involving multiple organizations and professions from various disciplines combined with a
working knowledge of medications, access to accurate and complete patient information and integration of interrelated decisions over a period of time.
Appropriate medication use
have traditionally operated under the assumption that if care providers are well educated and follow well-developed policies, procedures, or guidelines, errors will not happen.
Health care systems
must come to a common understanding regarding medication errors, reporting requirements, and risks to capture and act upon error potential within their own medication use systems.
Organizations
2 types of ADEs:
(1) those caused by errors
(2) those that occur despite proper usage of a medication.
If an ADE is caused by an error, it is by definition,
preventable.
Nonpreventable ADE (injury, but no error)
Adverse drug reactions
Preventable ADE
An injury due to an error in the use of a drug (including failure to use).
a serious medication error—one that has the potential to cause an ADE, but did not, either by luck (e.g, the patient was not allergic to the drug despite a note in the record stating so) or because it was intercepted
Potential Adverse Drug Event (PADE):
an ADR does not result from an error.
Adverse Drug Reaction (ADR)
Understanding the error:
▪ Medication errors are considered preventable while adverse drug reactions are generally are not.
▪ If an error occurs, but is intercepted by someone in the process, it might not result in an adverse event. These potential adverse events are often referred to as near misses.
▪ Capturing information regarding near misses could yield vital information regarding system performance.
▪ Increased patient complexity and decreased numbers of health care staff contribute to potential error.
- A ________ is demanded in health care.
zero error standard
IOM’s Chasm offers four recommendations for a tiered strategy:
▪ Establish a national focus on patient safety
▪ Identify and learn from errors
▪ Raise standards and expectations for improvement in safety
▪ Create safety systems inside health care organizations
is based on systems theory and the work of Deming, Senge, Wheatley, and others who applied systems thinking
to concepts of organizational development, improvement, and leadership.
microsystems concept
defined as small, organized groups of providers and staff caring for defined populations of patients
Microsystems
Targeting Medication Safety at the Microsystem level:
- Focus on the microsystem offers the potential for greater
standardization of common activities. - An increased use and analysis of information and medical evidence
- Constant measurement and feedback of data.
Understanding medication use process:
Medication use complication and errors can occur in all patient care settings; no patient care arena is immune.
N/A
tend to make the same medication mistakes over and over because members tend to accuse individual employees rather than consider the real root cause of the error, a faulty system.
A variety of factors can influence individual and team performance. Of growing concern are the effects of burnout, stress, and fatigue.
Health care organizations
Safety Culture:
- Culture is based on values.
- Leaders and top management
- Communication from the top down
- Perceived messages must resonate with workers
- Reward systems
- Promotions, salary adjustment, approval, and reinforcement mechanisms.
Linking safety & Performance improvement:
This wake-up call for health care has inspired many organizations to rededicate their focus on identifying, measuring, and implementing performance improvement strategies to strive for better care services.
N/A
This learning cycle, has been advocated for use by health care systems to improve processes affecting patient care.
The model was initially by Thomas Nolan and his colleagues at Associates in Process Improvement.
Plan-Do-Study-Act
is a basic quality improvement process that allows an organization to test and analyze a change on a small scale to determine whether it is improving a process or making it more efficient.
PLAN-DO-STUDY-ACT
is dependent upon the work of a team that has an interest in evaluating a change and has knowledge of what the current process is and is capable of being.
Plan-Do-Study-Act (PDSA) process
PDSA Cycle:
PLAN - Describe objective, change being tested, predictions, needed action steps, plan for collecting data.
DO - run the test, describe what happens, collect data
STUDY - analyze data, compare outcome to predictions, summarize what you learned
ACT - decide what’s next, make changes, and start another cycle.
Tools to Identify, Control, Contain, or Mitigate risk
- When adverse events occur, health systems must identify the causes of the event, the interrelationship of these causes, and implement improvement or redesign efforts to
eliminate causes of error. - Since errors are thought to be preventable, organizations must also identify methods to design or redesign systems proactively.
- These proactive efforts are aimed to prevent, or at least minimize, the likelihood that failures occur and also protect patients from the effects of failures when they do occur.
