PS 102: From Error to Harm

Psychological harm:

Psychological harm: What about all those experiences that don't require additional medical care, but injure patients psychologically? Is it a harm when a provider rudely wakes a patient up in the night for no medical reason, when her privacy is violated, or when a provider callously delivers a cancer diagnosis? To patients, this is an incredibly important type of harm. It's difficult to define and measure, but every provider has the power to alleviate a patient's emotional suffering by showing empathy.

violation

a deliberate deviation from an operating procedure, standard, or rules."

mistake

an action goes as intended but is the wrong one, involves a failure in planning

Latent conditions

are defects in the design and organization of processes and systems; things like poor equipment design, inadequate training, or insufficient resources. These errors are often unrecognized or just become accepted aspects of the work, and their effects are delayed.

What intervention helped prove that catheter-associated bloodstream infections (CLABSIs) were preventable consequences of care? (A) A new guideline that required all staff to wash their hands with alcohol and soap before inserting a catheter (B) A checklist of evidence-based practices applied consistently and collectively every time a catheter is used (C) A new device that no longer required catheters to inject medications and draw blood (D) A new standard that encouraged providers to take patients off ventilators sooner

A checklist of evidence-based practices applied consistently and collectively every time a catheter is used The correct answer is B, a set of evidence-based practices applied consistently and collectively. Reductions in CLABSIs are due to this improvement of the system for placing catheters, not technical innovation or isolated guidelines. Ventilators aren't related to bloodstream infections.

According to James Reason, by definition an "unsafe act" always includes: (A) A potential hazard (B) Harm to one or more patients (C) One or more mistakes (D) All of the above

A potential hazard James Reason calls unsafe acts errors or violations committed in the presence of a potential hazard. Errors can be further divided into slips, lapses, and mistakes. They may or may not actually result in harm, but the potential for harm is present.

The Swiss cheese model of harm illustrates what important concept in patient safety? (A) Unsafe acts (including errors and violations) are the most important cause of harm to patients. (B) Both latent unsafe conditions and active failures (unsafe acts) contribute to harm. (C) Harm results when the layers of defense in a system fail to prevent a hazard from reaching a patient. (D) B and C

B and C The correct answer is D. The Swiss cheese model illustrates how a hazard results in harm by passing through the many "holes" in a safety system, which represent unsafe conditions that lead to unsafe acts and fail to prevent them from causing harm. By understanding the Swiss cheese model of harm, we can see that safety is the result of a system and not just the acts of providers.

Why do some patient safety leaders such as Dr. David Bates believe the definition of harm should be broader than the definition in the IHI Global Trigger Tool? (A) Because health care systems have eliminated all harms included in the current definition (B) Because expanding the definition of harm would make it easier to measure (C) Because health care systems should work to prevent more types of harm than the current definition includes (D) Because health care providers aren't usually concerned about harms such as psychological injury

Because health care systems should work to prevent more types of harm than the current definition includes The correct answer is C, because health care systems should work to prevent more types of harm than the current definition includes. Dr. David Bates and other leaders in the field of patient safety argue that health systems should be more expansive in their definition of harm because the definition affects the scope of improvement work. They believe that health systems can and should prevent more types of harm than the definition includes.

To prevent this problem from happening again, which of the following would be the best course of action? (A) Punish the resident and the pharmacist for their careless actions. (B) Require both the resident and the pharmacist to take additional training. (C) Develop a system that prevents messy handwriting from causing miscommunication that leads to error. (D) Ensure that no prescribing physician is ever tired or distracted.

Develop a system that prevents messy handwriting from causing miscommunication that leads to error. The best answer is to develop a system that prevents messy handwriting from causing confusion that leads to error. For example, the organization could switch to an electronic ordering system. Mandating additional training and/or punishing the resident and pharmacist for an unintentional error won't prevent them or anyone else from making the same mistake in the future. Providers are human beings, and there will always be days when they're tired or distracted.

"Knowledge-based errors" are best defined as: (A) Errors in the design and organization of processes and systems (B) Errors in problem-solving and decision making (C) Errors in patient care that don't result in injury and thus go undetected (D) Errors in automatic functioning

Errors in problem-solving and decision making A "knowledge-based error" is an error in problem-solving and decision making. In contrast to automatic thinking, problem-solving is slow, conscious, sequential, and often requires considerable effort. Errors in automatic functioning are called "slips."

Financial harm:

Financial harm: In the United States, medical bills are the leading cause of personal bankruptcy, and force families to deplete their savings, lose their homes, and put off needed health care.4 Avoidable health crises can also force people to take time off of work. In many cases, families are forced into extreme poverty because of high medical bills. The advocacy group Costs of Care points out that physicians have a big role to play in reducing the cost of care. (You can learn more about value-based care in TA 103: Quality, Cost, and Value in Health Care.)

What is one reason that patient safety has shifted to work on reducing harm in addition to preventing errors? (A) Human error has become less common in health care. (B) Harm is more preventable than providers once thought. (C) Identifying errors rarely leads to improvement. (D) Patients are only concerned about errors that cause harm.

Harm is more preventable than providers once thought. The correct answer is B, that harm is more preventable than providers once thought. A good example is central line-associated bloodstream infections (CLABSIs), a small number of which were once thought to be an inevitable complication of life-saving health care. Providers realized that it was actually possible to almost eliminate central-line infections through improvement efforts including a checklist to ensure all precautions were taken every time. Human error is still a big problem in health care, but reducing error is not the only way to reduce harm. Identifying errors is an important part of improvement, because it allows health care systems to improve unsafe conditions before they cause harm. Patients care about errors, in addition to harm, because errors undermine trust in the health care system.

Which of the following is the most significant advantage of shifting to a systems view of safety within health care? (A) It is easier to identify and remove people who are unsafe (B) It allows us to change the conditions under which humans work (C) It prevents human mistakes (D) It allows us to view unsafe acts as violations (E) All of the above

It allows us to change the conditions under which humans work Having a systems view of health care allows us to change the conditions under which humans work by recognizing that humans are not perfect and systems have a significant role to play in safety. This view is applicable in all patient care settings, as all care settings these days are complex.

Anita, a nurse practitioner, is seeing Mr. Drummond in clinic. Mr. Drummond is a 57-year-old man with diabetes and chronic kidney disease. Having kept up on the literature, Anita is aware that tightly controlling his diabetes can slow the progression of his renal disease. She discusses her plan to increase his dose of glargine (long-acting insulin) by 12 units per day with one of the family physicians in the clinic, who agrees. At the end of the day, as she is working on her documentation, she realizes she never told Mr. Drummond to increase his insulin dose. This is an example of what type of error? (A) Lapse (B) Mistake (C) Slip (D) Error of planning (E) Violation

Lapse Anita had a memory failure, which is a classic lapse. She understood what should be done and created a good plan. She even discussed it with a co-worker. However, in the midst of a busy clinic schedule she likely got distracted and forgot to implement the plan.

At University Hospital, the rate of Clostridium Difficile colitis has doubled during the past year. After reviewing the data, the hospital's senior leaders conclude that this is due to poor hand hygiene on the part of the staff, even though they have a clear hand washing policy in place and don't believe most staff are intentionally disregarding the policy. They decide to start a hand washing campaign and post signs all over the hospital reminding providers to wash their hands. What type of error is this intervention best designed to address? (A) Mistake (B) Slip (C) Lapse (D) Error of Planning (E) Violation

Lapse Signs and other reminders are good strategies for addressing lapses, specifically memory failure, which is what the leadership believes is generally happening in this hospital. While these types of campaigns may also address violations or mistakes, they are generally less successful in these areas.

Nearing the end of her 18-hour work shift, a resident sees a patient with extremely high blood glucose levels. She writes the patient a prescription for insulin; however, in her exhaustion, she closes her "U" (for "units"), and it looks more like an extra zero. As a result, the pharmacist dispenses an insulin dose that's ten times stronger than the patient needs. Which of the following is a latent unsafe condition that contributes to the resident's error? (A) Long work schedule (B) Fatigue (C) Anxiety (D) None of the above

Long work schedule The correct answer is the resident's long work schedule. Latent conditions are flaws in the design of systems that create opportunities for error.

Errors of omission

Most definitions of harm have focused on errors of commission — something that health care providers did that resulted in harm. For example, a patient who received too much of an anticoagulant and then suffers a stroke experienced an error of commission. But what about errors of omission — something that health care providers failed to do? For example, on the last page, the patient whose test results went without follow-up and then suffered a stroke experienced an act of omission.

Which of the following is included in the IHI Global Trigger Tool definition of harm? (A) Psychological harm such as a miscommunication about a diagnosis (B) Financial harm from expensive medical bills (C) The absence of needed care that contributes to harm, such as missed treatment for hypertension that leads to a stroke (D) Physical injury caused by medical care that triggers additional care

Physical injury caused by medical care that triggers additional care The correct answer is D, physical injury. Some patient safety leaders want to expand the definition of harm and include the other types of harm listed in this question, including financial harm, psychological harm, and so-called errors of omission, but those are not included in the IHI Global Trigger Tool definition of harm.

Slip: Lapse: Mistake: Violation:

Slip: Experience a slip and grab a medication that is different than one she intended to grab. Lapse: Have a lapse in memory and forget about her patient's known drug allergy. Mistake: Make a mistake by misjudging the likelihood that a harmful interaction could occur. Violation: Commit a violation by skipping the use of a historically malfunctioning bar-coding system, even though it's protocol, because you think, "It's probably broken anyway."

Two women — one named Camilla Tyler, the other named Camilla Taylor — arrive at a particularly busy emergency department at about the same time. Ms. Tyler needs a sedative, and Ms. Taylor needs an antibiotic. The doctor orders the medications but mixes up the patients when filling out the order sheets. The pharmacist dispenses the medications as ordered, and the nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. What is one of the latent errors in this scenario? (A) The emergency department is particularly busy. (B) The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. (C) The forms are completed by hand at the same time for different patients. (D) The two patients in this case have very similar names.

The forms are completed by hand at the same time for different patients. Latent errors would include any systemic problems that allowed the potential for an active error to occur and lead to patient harm. In this case, the fact that the forms were completed by hand at the same time for different patients turned out to be a latent error. The busy department and patients with similar names were not errors; they are just inherently challenging qualities of the system.

What is the active error in this scenario? (A) The forms are completed by hand at the same time for different patients. (B) The emergency department is particularly busy. (C) The pharmacist doesn't notice that the order sheets are incorrectly filled out. (D) The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.

The nurse administers an antibiotic to Ms. Tyler and a sedative to Ms. Taylor. The active error is the human error that led to patient harm. In this case, it's the nurse administering an antibiotic to Ms. Tyler and a sedative to Ms. Taylor.

Roger, a pharmacist in a hospital, is working in the discharge pharmacy filling medications for patients who are going home. He sees a prescription for ciprofloxacin, an antibiotic, and he asks his pharmacy technician Mike to fill it quickly, as the patient is waiting and anxious to leave. Mike checks the shelves and sees they are out of ciprofloxacin, but they do have levofloxacin (an antibiotic in the same class that covers most, but not all, of the same types of infections). Mike knows he should usually check with the prescribing physician before making a substitution. However, in the interest of efficiency in this particular case, Mike deems it OK to go ahead. He substitutes the medications. This is an example of what type of unsafe act? (A) Mistake (B) Slip (C) Lapse (D) Error of planning (E) Violation

Violation This is a violation because Mike made a deliberate decision to disregard standard procedure when he changed antibiotics for this patient without the prescriber's authorization. This change may result in harm if the levofloxacin does not treat the organism and site of infection.

Active failures

errors whose effects are felt immediately. Active failures are generally readily apparent — e.g., someone pushing an incorrect button or ignoring a warning light — and almost always involve someone at the front line. While the person on the front line — the doctor, nurse, or pharmacist — might be the proximal "cause" of the active error, the real root causes of the error have often been present within the system for a long time

lapse

if it is not observable. An example of a lapse is some form of memory failure, such as failing to administer a medication — no one can see your memory fail, so the error is not observable.

action does not go as intended, is a so-called error of execution and may be further described as being either a slip

if the action is observable An example of a slip is accidentally pushing the wrong button on a piece of equipment — you and others can see that you pushed the wrong button

knowledge-based mistakes

knowledge-based mistakes (the person does not have the necessary knowledge she needs to respond to the situation correctly).

rule-based mistakes

rule-based mistakes (the person has the knowledge he needs to respond correctly to the situation but applies it wrong

Swiss cheese model of accident causation

the idea that harm is caused by a series of systemic failures in the presence of hazard.