Preventing medical errors by designing benign failures

Incident learning in radiation oncology: A review

Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS, challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.

The Effect of Absenteeism and Clinic Protocol on Health Outcomes: The Case of Mother-to-Child Transmission of HIV in Kenya

Absenteeism of health workers in developing countries is widespread with some estimates indicating rates of provider absence of nearly 40% (Chaudhury et. al. 2006). This is the first paper to present evidence of the impact of health provider absence combined with limitations in health clinic protocol on health outcomes. Using longitudinal data from nearly 600 ante-natal care seekers at a rural ante-natal clinic in Western Kenya, we find that nurse absence on a patient's first visit significantly reduces the probability that a woman tests for HIV over her entire pregnancy. Since the benefits of PMTCT services depend on HIV status, we proxy HIV status with self-reported pre-test expectations of being HIV-positive and estimate the heterogeneous impact of absence based on these self-reported expectations. We find that women with a high pre-test expectation of testing HIV-positive and whose first ANC visit coincides with nurse attendance are 25 percentage points more likely to deliver in a hospital or health center, 7.4 percentage points more likely to receive PMTCT medication, 9 percentage points less likely to breastfeed and 10 percentage points more likely to enroll in the free AIDS treatment program at the clinic than similar women whose first visit coincides with nurse absence. The procedural shortcomings in our study setting, shortcomings that do not enable pregnant women to test on a subsequent clinic visit, appear common in other countries in sub-Saharan Africa. They suggest that nurse absence in the context of this medical system translates into sizable reductions in child and maternal health.

[Understanding mistake-proofing]

The mistake-proofing concept often refers to physical devices that prevent actors from making a wrong action. In anaesthesiology, one immediately thinks to specific design of outlets for medical gases. More generally, the principle of mistake-proofing is to avoid an error, by placing knowledge in the world rather than knowledge in the head. As it often happens in risk management, healthcare has received information transfers from the industry. Computer is changing the concept of mistake-proofing, initially based on physical design, such as aerospace and automotive industry. The mistake-proofing concept may be applied to prevention, detection, and mitigation of errors. The forcing functions are a specific part of mistake-proofing: they prevent a wrong action or they force a virtuous one. Grout proposes a little shortcut to identify mistake-proofing devices: "If it is not possible to picture it in action, it is probably not a mistake-proofing device".

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis

PURPOSE

Failure mode and effects analysis (FMEA) is a widely used tool for prospectively evaluating safety and reliability. We report our experiences in applying FMEA in the setting of radiation oncology.

METHODS AND MATERIALS

We performed an FMEA analysis for our external beam radiation therapy service, which consisted of the following tasks: (1) create a visual map of the process, (2) identify possible failure modes; assign risk probability numbers (RPN) to each failure mode based on tabulated scores for the severity, frequency of occurrence, and detectability, each on a scale of 1 to 10; and (3) identify improvements that are both feasible and effective. The RPN scores can span a range of 1 to 1000, with higher scores indicating the relative importance of a given failure mode.

RESULTS

Our process map consisted of 269 different nodes. We identified 127 possible failure modes with RPN scores ranging from 2 to 160. Fifteen of the top-ranked failure modes were considered for process improvements, representing RPN scores of 75 and more. These specific improvement suggestions were incorporated into our practice with a review and implementation by each department team responsible for the process.

CONCLUSIONS

The FMEA technique provides a systematic method for finding vulnerabilities in a process before they result in an error. The FMEA framework can naturally incorporate further quantification and monitoring. A general-use system for incident and near miss reporting would be useful in this regard.

Getting surgery right

OBJECTIVE

We sought to identify factors contributing to wrong-site surgery (wrong patient, procedure, side, or part).

METHODS

We examined all reports from all hospitals and ambulatory surgical centers--in a state that requires reporting of wrong-site surgery--from the initiation of the reporting requirement in June 2004 through December 2006.

RESULTS

Over 30 months, there were 427 reports of near misses (253) or surgical interventions started (174) involving the wrong patient (34), wrong procedure (39), wrong side (298), and/or wrong part (60); 83 patients had incorrect procedures done to completion. Procedures on the lower extremities were the most common (30%). Common contributions to errors resulting in the initiation of wrong-site surgery involved patient positioning (20) and anesthesia interventions (29) before any planned time-out process, not verifying consents (22) or site markings (16), and not doing a proper time-out process (17). Actions involving operating surgeons contributed to 92. Common sources of successful recovery to prevent wrong-site surgery were patients (57), circulating nurses (30), and verifying consents (43). Interestingly, 31 formal time-out processes were unsuccessful in preventing "wrong" surgery.

CONCLUSIONS

Wrong-site surgery continues to occur regularly, especially wrong-side surgery, even with formal site verification. Many errors occur before the time-out; some persist despite the verification protocol. Patients and nurses are the surgeons' best allies. Verification, starting with verification of the consent, needs to occur at multiple points before the incision.

Mistake proofing: changing designs to reduce error

Mistake proofing uses changes in the physical design of processes to reduce human error. It can be used to change designs in ways that prevent errors from occurring, to detect errors after they occur but before harm occurs, to allow processes to fail safely, or to alter the work environment to reduce the chance of errors. Effective mistake proofing design changes should initially be effective in reducing harm, be inexpensive, and easily implemented. Over time these design changes should make life easier and speed up the process. Ideally, the design changes should increase patients' and visitors' understanding of the process. These designs should themselves be mistake proofed and follow the good design practices of other disciplines.

Operational failures and interruptions in hospital nursing

OBJECTIVE

To describe the work environment of hospital nurses with particular focus on the performance of work systems supplying information, materials, and equipment for patient care.

DATA SOURCES

Primary observation, semistructured interviews, and surveys of hospital nurses.

STUDY DESIGN

We sampled a cross-sectional group of six U.S. hospitals to examine the frequency of work system failures and their impact on nurse productivity.

DATA COLLECTION

We collected minute-by-minute data on the activities of 11 nurses. In addition, we conducted interviews with six of these nurses using questions related to obstacles to care. Finally, we created and administered two surveys in 48 nursing units, one for nurses and one for managers, asking about the frequency of specific work system failures.

PRINCIPAL FINDINGS

Nurses we observed experienced an average of 8.4 work system failures per 8-hour shift. The five most frequent types of failures, accounting for 6.4 of these obstacles, involved medications, orders, supplies, staffing, and equipment. Survey questions asking nurses how frequently they experienced these five categories of obstacles yielded similar frequencies. For an average 8-hour shift, the average task time was only 3.1 minutes, and in spite of this, nurses were interrupted mid-task an average of eight times per shift.

CONCLUSIONS

Our findings suggest that nurse effectiveness can be increased by creating improvement processes triggered by the occurrence of work system failures, with the goal of reducing future occurrences. Second, given that nursing work is fragmented and unpredictable, designing processes that are robust to interruption can help prevent errors.

Getting the right blood to the right patient: the contribution of near-miss event reporting and barrier analysis

Safety and reliability in blood transfusion are not static, but are dynamic non-events. Since performance deviations continually occur in complex systems, their detection and correction must be accomplished over and over again. Non-conformance must be detected early enough to allow for recovery or mitigation. Near-miss events afford early detection of possible system weaknesses and provide an early chance at correction. National event reporting systems, both voluntary and involuntary, have begun to include near-miss reporting in their classification schemes, raising awareness for their detection. MERS-TM is a voluntary safety reporting initiative in transfusion. Currently 22 hospitals submit reports anonymously to a central database which supports analysis of a hospital's own data and that of an aggregate database. The system encourages reporting of near-miss events, where the patient is protected from receiving an unsuitable or incorrect blood component due to a planned or unplanned recovery step. MERS-TM data suggest approximately 90% of events are near-misses, with 10% caught after issue but before transfusion. Near-miss reporting may increase total reports ten-fold. The ratio of near-misses to events with harm is 339:1, consistent with other industries' ratio of 300:1, which has been proposed as a measure of reporting in event reporting systems. Use of a risk matrix and an event's relation to protective barriers allow prioritization of these events. Near-misses recovered by planned barriers occur ten times more frequently then unplanned recoveries. A bedside check of the patient's identity with that on the blood component is an essential, final barrier. How the typical two person check is performed, is critical. Even properly done, this check is ineffective against sampling and testing errors. Blood testing at bedside just prior to transfusion minimizes the risk of such upstream events. However, even with simple and well designed devices, training may be a critical issue. Sample errors account for more than half of reported events. The most dangerous miscollection is a blood sample passing acceptance with no previous patient results for comparison. Bar code labels or collection of a second sample may counter this upstream vulnerability. Further upstream barriers have been proposed to counter the precariousness of urgent blood sample collection in a changing unstable situation. One, a linking device, allows safer labeling of tubes away from the bedside, the second, a forcing function, prevents omission of critical patient identification steps. Errors in the blood bank itself account for 15% of errors with a high potential severity. In one such event, a component incorrectly issued, but safely detected prior to transfusion, focused attention on multitasking's contribution to laboratory error. In sum, use of near-miss information, by enhancing barriers supporting error prevention and mitigation, increases our capacity to get the right blood to the right patient.

Klinisches Risikomanagement

BACKGROUND

The main goal of a medical risk management system is reduction of treatment errors and the primary focus is patient safety.

MATERIALS AND METHODS

A task force on risk management in anaesthesia was established in the department of Anaesthesiology and Intensive Care at the University Hospital Dresden with the aim to implement a critical incident reporting system (CIRS) followed by a structured analysis. The theoretical basic principles and tools for the incident analysis are presented.

RESULTS

The task force developed a machine-readable, structured, anonymous questionnaire, which was implemented in clinical practice after a primary test period.

CONCLUSIONS

Prerequisites for the implementation of an effective CIRS are support from the department head, anonymity, independence of the task force from the department head and competence of the task force to initiate changes and improvements. CIRS is a powerful tool to register and analyse critical incidents and may influence the following domains: education and training (human factors), medical equipment (technical factors), quality of working processes and departmental communication (organisational factors).