Err is human ....how could we minimize the preventable medical errors in our healthcare organization

1. Dr Inas Alassar
CPHQ

2.  “Quality” means those features of
products which meet customer needs and
thereby provide customer satisfaction.
The purpose of such higher quality is to
provide greater customer satisfaction
and, one hopes, to increase income.
JURAN …

3.  "Quality is never an accident; it is always the
result of high intention, sincere
effort, intelligent direction, and skillfull
execution. It represents the wise choice of
many alternatives.
" William A. Foster,

4.  IOM :
Quality of care is the degree to which health
services for individuals and populations
increase the likelihood of desired health
outcomes and are consistent with current
professional knowledge.

6.  Measurable quality :
can be defined objectively as compliance
with, or adherence to, standards / Risk /
cost .

7.  2. Appreciative quality
is the excellence beyond minimal standards and
criteria, requiring judgments of skilled,
experienced practitioners and sensitive, caring
persons.
 Experience/ ethics / peer review
.

8.  3. Perceptive quality :
is that degree of excellence that is perceived
and judged by the recipient or the observer
of care rather than by the provider of care .

9. Dimensions of Quality
APPROPRIATENESS EFFICIENCY
AVILABILITY
PREVENTION /
EARLY DETECTION
COMPETENCY RESPECT AND CARE
CONTINUITY SAFETY
EFFECTIVENESS TIMELINESS
EFFICACY

10. Simply , Quality is …..
DOING THE RIGHT THINGS RIGHT FROM
THE FIRST TIME
AND IMPROVE IT EVERY TIME (CQI ).
EFFICINECY
EFFECTIVNESS
APPROPRIATENESS

11. S
T
E
E
E
P

12. Patient- and Family-Centered Care
It s a series of values or principles:
Dignity and Respect
We listen to and honor patient and family perspectives
and choices. We incorporate patient and family
knowledge, values, beliefs, and cultural background into
care planning and delivery.
Information Sharing
We communicate and share complete and unbiased
information with patients and families in affirming and
useful ways. Patients and families receive timely and
accurate information so they may effectively participate
in care and decision-making.

13. Participation
We encourage patients and families to participate in care and
decision-making at the level they choose.
Collaboration
We invite patients and family members to work with our care
providers and hospital leaders on policy and program
development, execution, and evaluation; in health care facility
design; and in professional education and care delivery.
Access
The care we provide is equitable and flexible, and is delivered
as efficiently and timely as possible.
Care Coordination
We focus on the coordination of patient care and patient and
family needs. Our health care teams are trained, and our
systems are designed, to support transition, integration, and
continuity of care. Emphasis is placed on continuous healing
relationships.

14. TO ERR IS HUMAN
To err is to make a mistake… To make a mistake is human.
Humans are not perfect. They make mistakes….!
-An important point to realize about errors is that people never make them
intentionally.
-If someone does intentionally do the wrong thing, that is not an error but
a premeditated ( planned ) act that should be recognized and addressed .
-To understand why people make errors, first we need to understand
normal mental functioning.
-Cognitive psychologists have been studying this for decades and states
that much of our mental functioning is automatic, rapid, and effortless.
-At other times, we’re deeply engaged in solving problems – often a slow
process involving a great deal of effort.
- Both kinds of mental functioning are prone to error.

15. A woman dies from untreated internal bleeding.
A patient and her family are hit by a flurry of medical
errors during a long hospital stay.
A pharmacist is devastated when fatal mistakes occur
on his watch.
- In this topic , you’ll find out just how many people
are affected by medical errors worldwide.
-Finally, you’ll explore the reasons that providing safe
care isn’t always easy in an environment in which
powerful drugs, quick decisions, and persistent
distractions are the norm.

16. “First, do no harm.”
This phrase is one of the most familiar tenets of the health
care profession.
If you poll a group of health care professionals, it is likely
that most — if not all —
would say they strive to embrace this motto in their
practice. And yet,
patients are inadvertently harmed every day in the health
care system, sometimes with severe consequences

17. Ensuring the patient s safety
What does that mean, exactly?
According to the World Health Organization,
patient safety means offering "freedom…from
unnecessary harm or potential harm associated with
healthcare."
A focus on safety can also reduce the severity of
harm, should it occur

18. Wrapping Your Head Around
the Problem of Medical Error
In 1999, the Institute of Medicine (IOM) released its landmark report,
To Err Is Human,
which stated that between 44,000 and 98,000 people die each year
in US hospitals due to medical errors.
That is more than the number of people who die in a given
year from motor vehicle accidents, breast cancer, or AIDs.

19. Since the 1999 IOM report, statistics from around the world continue to point
to a very real and significant problem. Consider the following data:
A study from 2000 showed that during one year, as many as 18,000 patients
in Australia died from medical errors and more than 50,000 patients were
disabled.
Also in 2000, the Centers for Disease Control and Prevention (CDC) revealed
that each year nearly 2 million patients in the United States get an infection
while being treated for another illness or injury, and nearly 88,000 die as a
direct or indirect result of this infection — adding nearly $5 billion to health
care costs every year.
A 2001 study showed that nearly 12 percent of hospital admissions in the
United Kingdom involve some form of adverse event

20. Why Are Errors Occurring?Why Are Errors Occurring?
There are many answers to that question.
The following are some of the more direct
reasons:
1-Diagnosing and treating patients is incredibly
complex.
2-Practitioners are often not adequately trained
or prepared to deliver care as a well-integrated
team.

21. 3-Errors often occur as a result of flawed processes or
systems of care — not because of negligent or
irresponsible individuals.
4-The culture of safety — "the attitudes, beliefs,
perceptions, and values that employees share in
relation to safety"— that exists in most health care
organizations is weak compared to many other high-
risk, complex businesses such as the airline, petroleum,
and nuclear power industries

22. 5-As the practice of medicine advances, the complexity
and the number of steps in any one care process also
increase.
-Delivering safe, appropriate, timely care to multiple
patients, many of whom cannot read or understand
complex medical terminology, is challenging
- In addition, there is not one "right" way to practice
medicine — although evidence-based medicine does
support recommended practices for many care processes
— and the science of medicine is filled with nuance and
gray areas.

23. Consider the following scenario
Early one evening, at the beginning of a new shift, Janet needs to obtain
blood samples for four of her patients. She collects one sample and,
before she gets
a chance to label it, she is called to help with another patient who is
having an emergency. One of her colleagues called in sick and the unit is
woefully understaffed, so she cannot give her blood sampling duties to
someone else; she must put them on hold. Janet places the unlabeled
specimen on the nurse's station with a sticky note nearby indicating
the patient's name. She then goes to help with the other patient.
After completing her work with the emergent patient, Janet returns to
the nurse's
station and discovers four unlabeled vials of blood and no sticky note.
She realizes that another nurse on the unit is obtaining blood samples
from his patients and was also called away. Now, both nurses have
no idea which vials belong to which patients. Does it seem likely
that a medical error is about to occur?

24. Although the previous example illustrates some of the reasons
why medicine is so complex — multiple patients, staffing
issues, time-sensitive care, competing priorities — there are
many others:
-powerful drugs
-highly technical equipment
-rapid decisions made under time pressure
-many caregivers and multiple “handoffs”
-limited resources
-highly acute illness and injuries
-an environment full of distractions
-variable patient volume

25. In addition, here are more reasons:
-There is not a high degree of agreement on what
constitutes best practice within the medical field,
despite the fact that evidence-based medicine does
support many recommended practices.
-What one health care organization feels is good
practice, another may not.
- When providers work in multiple institutions, this
inconsistency may be problematic.
-Diagnosis and treatment are often performed under
some degree of uncertainty, requiring providers to
make quick decisions based on insufficient
information.

26. •Medication monitoring, particularly in the outpatient
setting, is quite challenging
• because the patient goes home and may or may not
take prescribed medications.
•For a front-line practitioner, there are always new
medications, new technologies, new procedures, and
new research findings to assimilate.

27. A New Perspective on Medical Error
Historically, the medical profession has viewed medical
errors as either an inevitable byproduct of complex care
or a result of provider incompetence, often seeking to
blame the providers involved in the error rather than
examining the systems that may have failed.
However, over the past ten years, health care
organizations have begun to realize and accept that most
errors cannot be linked to the performance of the
individual and are instead the result of a series of system
errors that work together to yield unsafe situations.

28. The Provider Response to Error
Patients and family members are not the only people to
be affected by medical error.
-The providers who experience those errors directly or
indirectly are also affected.
-As previously mentioned, the medical profession has
historically expected its own practitioners to be perfect
and if they would just try harder — free from mistakes.
Within this context, when an error occurs, the logical
extension is to blame the provider and "make sure" he
or she never makes the same mistake again. This
"blame and shame" approach has done little to further
the cause of patient safety and, in fact, has taken us a
step backward.

29. Going Forward
Safety has been defined by one industry leader as a “dynamic
non-event.”
-When things go right, nothing bad happens — nothing bad for
the patient, nothing bad for the family, and nothing bad for the
practitioner.
But to make "nothing bad happen" requires a lot of good things
to be done right.

30. -To make dramatic improvements in patient safety will
require the following commitments from both
individuals working in health care and the
organizations in which they work:
-Acknowledge the scope of the problem of medical
errors and make a clear commitment to redesign
systems to achieve higher levels of safety.
- -Recognize that most patient harm is caused by bad
systems and not bad people, and therefore we must end
our historic response to medical error, which has been
saddled with finger-pointing and shame.

31. -Acknowledge that individuals alone cannot improve
safety; it requires everyone on the care team to work
in partnership with one another and with patients and
families.
-To deliver the right care — for every patient, every
time — requires a new way of thinking about error in
medicine, and a new approach to preventing errors
and harm.
-To thoroughly understand and accept this approach,
you must first gain a deeper appreciation for error
causation and prevention .

32. Assessment
1) What does patient safety mean, according
to the World Health Organization?
a) Freedom from unnecessary harm or
potential harm associated with health care
b) Freedom from errors or potential errors
associated with health care
c) Freedom from death associated with health
care
d) Receiving the most state-of-art care
possible

33. 1) What does patient safety mean,
according to the World Health
Organization?
Correct Answer :a ) Freedom from
unnecessary harm or potential harm
associated with health care

34. A Cenario ….
James is a first-year surgery resident on his first pediatric
rotation. His attending (consultant) asks him to start
intravenous (IV) replacement fluids on a two-year-old who is
having vomiting and diarrhea.
-Having trouble remembering how to calculate fluid
replacement rates for very small children, James asks Maria,
a nurse on the unit. Maria responds, “You’re the doctor. It’s
your job to decide this.” James picks a rate, 75 cc per hour,
that puts the child into fluid overload. James is devastated.

35. What is one of the reasons that this error occurred?
a) James does not care about his patients’ safety
b) There is an inadequate culture of safety and
teamwork on the unit
c) Best practice is not clearly understood in this
patient’s case
d) The complexity of care led to the error

36. What is one of the reasons that this error occurred?
Correct Answer : b) There is an inadequate culture of
safety and teamwork on the unit
We can assume that James cares about patient safety,
like all health care providers. While errors do often
occur due to the complexity of care or the lack of
recognized best practice, in the case of IV fluid
replacement, clear recommendations do exist for how
to calculate these rates for children. In this case,
when James asked for help, Maria, instead of being a
team player, made James feel bad. James did not ask
for help again but instead chose a rate, and an error
occurred. Had there been a culture of safety fostering
better teamwork, this error may well have been
averted.

37. Which of the issues listed below is NOT a reason that
patients are harmed by medical errors?
a) Practitioners often do not know how to work well
in a team
b) Recommended practice may vary from one
institution to the next
c) The modern health care setting is very complex
d) Perfection is an unattainable goal, so harmful
errors are to be expected
e) New information takes a long time to be absorbed

38. Which of the issues listed below is NOT a reason that
patients are harmed by medical errors?
Correct Answer : d) Perfection is an unattainable goal,
so harmful errors are to be expected
Some providers and health care systems have
traditionally held the view that errors that cause harm
are an inevitable part of providing care. However,
when organizations design their systems to account for
the likelihood of human error, it is possible to prevent
those errors from causing harm.

39. Stan, a 92-year-old man with mild dementia and atrial
fibrillation (an abnormal heart rhythm), is admitted to the
hospital with pneumonia. He is placed on appropriate
antibiotics. His physicians note he is on warfarin, a blood
thinner that may interact with the antibiotics, so they order
an International Normalized Ratio (INR) test to check the
degree to which his blood is thinned. Stan’s INR level looks
fine one day after starting the antibiotics. He is ready to go
home the next day, and the pharmacist on the unit
recommends that Stan’s INR be checked in two or three days,
as it may take some time for the interaction to fully develop.
The discharging physician tells Stan and writes it on the
discharge form. Stan forgets, and he cannot get an
appointment with his clinic doctor for two weeks. One week
later he has a small stroke due to a bleed in his brain. His INR
at the time is found to be six (very high).
6) What is the MOST LIKELY outcome from this medical error?
a) Trust improves among providers
b) Patient satisfaction scores improve
c) The pharmacist quits practicing
d) Stan's family comes to the hospital for care

40. 6) What is the MOST LIKELY outcome from this
medical error?
Correct Answer :c) The pharmacist quits
practicing
Patients and families are not the only
“victims” of a medical error. Practitioners
suffer as well. In fact, some practitioners
leave their profession after committing errors
leading to a death.

41. 7) The “blame and shame” approach to
medical error:
a) Has moved patient safety forward
b) Is an effective tool in the patient safety
arsenal in certain circumstances
c) Encourages people to report errors
d) Reflects the understanding that human
perfection is unattainable
e) Adds to the negative effect of errors on
providers

42. 7) The “blame and shame” approach to medical error:
Correct Answer : e) Adds to the negative effect of errors
on providers
By singling out the person who committed the mistake,
the “blame and shame” approach fails to recognize that
human perfection is unattainable. This approach also fails
to reflect a systems-based understanding of how and why
errors occur. The “blame and shame” approach adds to
the harmful effects of errors by making providers feel as if
they are failures, when in fact their actions are only the
last in a long chain of errors leading to patient harm.

43. What Is Considered an
Unsafe Act?
an unsafe act as “an error or a violation
committed in the presence of a potential
hazard.
-According to Reason, unsafe acts may be
categorized as either errors or violations.
Errors may be further categorized as slips,
lapses, and mistakes.

44. Taking a Closer Look at Human Error
In his book Human Error, James Reason said that errors can be divided
into two types of failures:
An action does not go as intended.
An action goes as intended, but it’s the wrong one.
The first type of failure, in which an 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 — or a lapse, if it is not.

45. 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.
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.

46. The second type of failure, in which an action goes as
intended but is the wrong one, involves a failure in
planning.
-This category of error, is known as a mistake.
Here’s one example of a mistake:
During a physical exam, a physician detects a lump in the
right breast of a young, female patient. He’s convinced,
based on the patient’s age and family history, that the lump
could not be cancerous. He tells the patient that she
probably has fibrocystic breasts — a common, non-
cancerous condition — and he fails to pursue a more
definitive diagnosis. Later, it’s discovered that the lump is
in fact cancerous.

47. Taking a Closer Look at Violations
According to the World Health Organization (WHO),
a violation is “a deliberate deviation from an operating
procedure, standard or rules.”
Although deliberate (done intentionally ) , violations are not
necessarily the result of deviant behavior — “I know this is wrong, but
I am going to do it anyway!”

48. Let's look at an example
At the end of the day, a respiratory therapist is late for
picking up his children at day care. Because he is in a
hurry, he speeds up (instead of slowing down) at two
yellow lights, averaging about seven miles per hour above
the posted speed limits along his route. He calls the day
care facility on his cell phone while driving to let them
know he will be 10 minutes late. These are all examples of
violations, where the therapist either didn’t recognize the
risk he was taking or felt the risk was justified. He is not a
bad person, and he is not acting with conscious disregard
for safety, but his actions are potentially unsafe.

49. Human error in health care — slips, lapses, and mistakes — has the
potential to harm patients, depending on the nature of the error.
For example, you may “slip” and push an incorrect button that gives
the patient an overdose of medication.
-Likewise, you could have a “lapse” in memory, which causes you to
give an incorrect dose of a life-saving medication.
- You may make a “mistake” and misdiagnose a patient, giving him
or her treatment that supports the misdiagnosis and leads to severe
harm.
Violations can also lead to patient harm. Consider the nurse who is
working with a medication bar coding system that repeatedly breaks
down. One day she is rushing to give a patient his medication and
she skips using the bar coding system — figuring it's probably broken
anyway. Although not intending to, she is putting the patient at risk.

50. While we have been talking about how unsafe acts can lead to
medical error, the term “medical error” is slightly misleading as it
may give the impression that the kinds of errors that can occur in
health care are unique to health care.
This is not the case.
What is different about health care is that there remains an
element of “a culture of infallibility” — the idea that if we are
good at our jobs, we cannot make mistakes — that denies the
prevalence of error. And yet, error is very much a part of the
human condition, so just trying to be perfect is not a rational or
effective approach.

51. In health care, serious errors that lead to
patient harm are usually just like the previous
situation—made up of one or more errors, and
the opportunities to catch the errors are
missed, allowing the consequences of the
errors to slip through and cause harm. James
Reason, an internationally known expert on
error, has called this the Swiss cheese model.

52. Reason proposed what is referred to as
the “Swiss Cheese Model” of system
failure. Every step in a process has the
potential for failure, to varying
degrees. The ideal system is analogous
to a stack of slices of Swiss cheese.
Consider the holes to be opportunities
for a process to fail, and each of the
slices as “defensive layers” in the
process. An error may allow a proble
to pass through a hole in one layer, but
in the next layer the holes are in
different places, and the problem
should be caught. Each layer is a
defense against potential error
impacting the outcome.

53. For a catastrophic error to occur, the
holes need to align for each step in the
process allowing all defenses to be
defeated and resulting in an error. If the
layers are set up with all the holes lined
up, this is an inherently flawed system
that will allow a problem at the
beginning to progress all the way
through to adversely affect the
outcome. Each slice of cheese is an
opportunity to stop an error. The more
defenses you put up, the better. Also the
fewer the holes and the smaller the
holes, the more likely you are to
catch/stop errors that may occur.

54. Case Example #1:
A 28-year-old, significantly obese woman goes to a clinic,
complaining of calf pain that keeps getting worse. She tells her
primary care provider that she thinks the pain is due to the new
shoes she bought and her new commitment to walking and
exercising more. She describes her pain to the doctor as a 10 on
a scale of 1 to 10. The patient has no history of leg trauma, and
her only medication is a birth control pill. After examining her,
the doctor does not see anything unusual. The doctor prescribes
ibuprofen and muscle relaxants, and instructs the woman to
return to the clinic if her symptoms do not get better. A week
later, the woman returns to the clinic complaining of chest pain
and shortness of breath. Shortly after she transfers to the
emergency department, she has a heart attack and is unable to
be resuscitated. A post-mortem examination reveals a massive
blockage in the artery that passes through her lung.

55. Q What type of unsafe act, if
any, does this case
demonstrate?
a) Slip
b) Lapse
c) Mistake
d) Violation
e) There is no unsafe act in this case

56. Answer: C.
In this example, the physician who assessed the patient made an error — in
this case, a mistake. When the patient attributed her pain to new shoes and a
new exercise routine, the physician took that available information and
almost immediately concluded the patient had strained her calf muscle. Her
symptoms were representative of many other patients he had seen who try to
do too much exercise with too little preparation, too quickly. Anchored on his
diagnosis, he thought more about the treatment than he did about what other
factors might be causing her condition. While her obesity and use of birth
control medication were both factors predisposing her to deep venous
thrombosis (DVT) — blood clots — he became narrowly focused on next steps,
not appreciating something he already knew: his physical exam was an
unreliable strategy to determine the presence or absence of DVT.
Several days later when the doctor was told by a colleague that his patient
arrested in the emergency department, he knew almost immediately that the
post-mortem was going to reveal a massive blockage.
This example involves the concept of heuristics — cognitive shortcuts that
allow for rapid, often unconscious decision making. Unfortunately, heuristics
are also associated with cognitive biases that can be strong, but incorrect.

57. Case Example #2:
A 35-year-old man named John goes to the doctor for an
initial visit and to get a referral for the ophthalmologist.
After John's visit, the doctor is reviewing lab results for a
different patient, Bill, and these results indicate that Bill
is anemic and has blood in his stool, suggesting an ulcer
or cancer. The doctor mistakenly enters a referral for
John to the gastrointestinal (GI) lab for a colonoscopy.
The referral states John has blood in his stool and mild
anemia. John takes off work and prepares himself for the
procedure. The day after his colonoscopy, John calls the
provider who made the referral and asks when he was
tested for blood in his stool and if he really needed the
procedure. It is at this time that the doctor realizes that
John has undergone an unnecessary procedure and that it
has been ordered on the wrong patient.

58. a) Slip
b) Lapse
c) Mistake
d) Violation
e) There is no unsafe act in this case
What type of unsafe act, if any, does
this case demonstrate?

59. Answer: A.
In this example, the physician made a slip.
While reviewing Bill's lab results, the physician
still had John’s electronic medical record
open on the screen, and this medical record
“captured” the next step in the physician's
thought process, which was to make a referral
to GI. It was not until John called the
physician after the procedure was completed
that the doctor recognized his error

60. Case Example #3:
A 70-year-old woman is having issues with her bladder and rectum
that require surgery. During her surgery, a gauze sponge is placed
in her vagina to control bleeding. The patient goes to the
recovery area, from where she is to be directly discharged home.
Her doctor writes an order to remove the sponge prior to her
discharge but he does not communicate this to the patient or her
daughter, who is there to support her mother. The male nurse
assigned to the patient is working with a female nurse, who offers
to remove the patient's Foley catheter — a tube inserted into the
bladder to drain urine — and vaginal sponge. She removes the
catheter but gets interrupted and does not remove the sponge.
The male nurse assumes his colleague has removed the sponge
and does not double check this. The patient follows up with her
primary care provider seven days later because of vaginal pain
and the sponge protruding from her vagina.

61. Q What type of unsafe
act, if any, does this
case demonstrate?
a) Slip
b) Lapse
c) Mistake
d) Violation
e) There is no unsafe act in this case

62. Answer: B.
In this example, there were several lapses in
communication and execution of protocol that
contributed to the patient's medical error. While her
doctor wrote an order to remove the sponge prior to
discharge, he did not communicate that order directly
to the care team — as he typically did — nor to the
patient or her daughter. It turns out that the physician
had been up for 24 hours performing surgeries and
simply forgot. That was the first lapse. The female
nurse, who offered to remove the patient's Foley
catheter and vaginal sponge for her male colleague,
got interrupted in the process and remembered to
remove the Foley catheter but not the sponge. This
was the second lapse. The male nurse assigned to the
patient assumed the female nurse had removed the
sponge without actually verifying it. This was the third
lapse.

63. Case Example #4:
In the course of one week at a mid-sized hospital and nearby primary
care office, the following incidents took place:
A 52-year-old woman, with a history of ulcers and bleeding in her
gastrointestinal tract as a result of taking ibuprofen, is seen by a
doctor at the primary care office. After examining her, the physician
tries to prescribe ibuprofen to treat her condition. The medication
order entry system issues an alert — the 25th one that day — and the
physician ignores the alert without reviewing the patient's medical
record, thinking the alert is likely to be another "false alarm." Behind
on his schedule, he chooses to override the alert and prescribe the
ibuprofen. After taking the medication, the patient develops bleeding in
her gastrointestinal tract and has to be admitted to the hospital.

64. A pharmacist dispenses 5 mg of Methotrexate — a drug used
to treat certain types of cancer — instead of 5 mg of
Methimazole — a drug used to treat an overactive thyroid
condition. Before dispensing the medication, the pharmacist
takes a quick look at the drug label, but mostly relies on the
pharmacy storage location from which he pulls the drug and
the first four letters of the drug's name to convince him he has
the right medication for the patient. After taking the medication
at home, the patient gets nauseated, calls the pharmacy, and
returns the incorrect medication.
An order is placed for "100 cc/hr" of normal saline IV solution
for a 91-year-old inpatient on the medical-surgical floor. A
nurse is busy tending to the needs of the patient — trying to
locate some applesauce for her to eat and also setting up the
IV solution. Since she is busy, the nurse does not bring the
patient’s medical record into the room with her as required by
policy, and she remembers the patient's IV dose as 1,000 cc/hr
instead of 100 cc/hr. The patient receives 1,000 cc/hr for 2
hours before another nurse identifies the error at shift change.

65. Q What type of unsafe
act, if any, is
represented
throughout this case
example?
a) Slip
b) Lapse
c) Mistake
d) Violation
e) There is no unsafe act in this case

66. Answer: D.
An analysis of each of the incidents indicates that the unsafe
acts were not human error per se, but violations. Although it’s
easy to see why many of these violations occurred, they are
violations nevertheless.
The physician who ignored the medication order entry system
alert without reviewing the patient's medical record made a
conscious decision not to follow safe practice, convincing
himself that it was another false alarm and succumbing to the
time pressures of his busy schedule.
The pharmacist who dispensed the wrong drug chose not to
carefully read the label and compare it against the order he
received, per protocol. Instead, he relied on the storage
location of the drug and the first several letters of its spelling
to dispense the medication. This was not the practice he had
been taught.
The nurse who overdosed the patient created a shortcut to
facilitate getting her job done, making a decision not to bring
the patient’s medical record into the room per hospital policy,
and instead relying on her memory to safely administer the
medication. This was not a simple slip or lapse in
performance.

67. By focusing on the individual as the cause of error, organizations isolate
individual unsafe acts from the system context, which includes a multitude
of complex processes, in which they occur. As a result, the pursuit of greater
patient safety is seriously impeded by an approach that does not seek out
and remove the error-provoking properties within the larger system of care.
In other words, the health care profession's traditional approach to fixing
medical error is not valid anymore, if ever it was. There is another, more
effective way to prevent unsafe acts in health care.
By focusing more on the conditions under which individual providers and
care teams work, and by designing in workflow and defenses to avert errors,
health care organizations can minimize the conditions that lend themselves
to violations and put mechanisms in place to mitigate unsafe acts that may
nevertheless occur. This “systems approach” can be quite successful in
preventing medical error and making patients safe.
Now That We Know About Unsafe
Acts, What Can We Do About Them?

68. Let s think about this …
*Shifting to a systems view of safety within
healthcare:
a) Allows us to better identify and remove people
who are unsafe
b) Allows us to change the conditions under which
humans work
c) Is only realistic in the most complex care settings,
such as ICUs
d) Assumes that humans can be trained to make no
mistakes
e) Allows us to view unsafe acts as violations

69. *Shifting to a systems view of safety within
healthcare:
Correct Answer :b) Allows us to change the
conditions under which humans work
Having a systems view of healthcare recognizes
that humans are not perfect, and that 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.

70. After nine months, hand hygiene rates have significantly improved,
but infection rates are only slightly better. Further data analysis
reveals a previously unrecognized, significant explanation for the
infection rate rise: providers are using antibiotics at a much higher
rate in the hospital than is the norm for a hospital like theirs,
especially for upper respiratory infections. The extra antibiotic use
is predisposing patients to “super-infections” such as C. difficile.
What intervention is most likely to be effective?
a) Step up the hand-washing campaign
b) Work with physician leaders to educate providers about the high
infection rates and high antibiotic use rates
c) Design a patient handout describing the risks of a C. difficile
infection
d) Change the physician incentives so that the physicians are
penalized when they prescribe antibiotics

71. What intervention is most likely to be effective?
Correct Answer :b) Work with physician leaders
to educate providers about the high infection
rates and high antibiotic use rates
The over-prescribing of antibiotics is an
example of an error in planning, or a mistake.
The physicians in this example are utilizing
antibiotics more often than recommended, and
may not be considering the risks of antibiotic
overuse. The intervention should address the
main issue of the way physicians develop plans
for patient treatment.

72. According to James Reason, an “unsafe act”:
a) Is an error or a violation committed in the
presence of a potential hazard
b) Will always result in patient harm
c) Includes slips, lapses, and blunders
d) Is intentional on the part of the perpetrator

73. According to James Reason, an “unsafe
act”:
Correct Answer: a) Is an error or a
violation committed in the presence of a
potential hazard
James Reason calls unsafe acts errors or
violations. They are not always
intentional.
Additionally, they can be further divided
into slips, lapses, and mistakes.

74. A Call to Action — What YOU Can Do
Five Critical Behaviors to Improve Safety
You are a critical link in the chain of patient safety and must not take
that responsibility lightly. Here are five behaviors that any practitioner
can do to improve safety for patients in his or her direct care:
1. Follow written safety protocols
2. Speak up when you have concerns
3. Communicate clearly
4. Don’t let yourself or others get careless
5. Take care of yourself

75. Behavior One: Follow Written Safety
Protocols
Most, if not all, health care organizations have protocols in place
that help preserve patient safety.
-Some of these are standardized throughout the industry — for
example, administering antibiotics before surgery — and some
have been developed specifically for a particular organization —
for example, using different color-coded stickers on the medical
record to indicate a patient's risk for falls.
- Protocols are often developed through the analysis of trended
data or as a result of a single adverse outcome.

76. Other examples of protocols that may be relevant to your work include
the following:
Two patient identifiers: Protocols that require two separate patient
identifiers can help make sure you accurately identify a patient prior
to the administration of a medication or the drawing of blood, for
example.
Alarm monitoring: These protocols ensure that physiologic monitoring
systems intended to protect patients are not ignored or inappropriately
inactivated.
Specimen labeling and handling: These policies and procedures ensure
specimens are not lost or incorrectly labeled, resulting in a repeat
draw, a delay in diagnosis or treatment, or a “wrong-patient, -site, or -
procedure” event.
Equipment disinfection/sterilization: These procedures minimize the
risk of infection caused by improperly disinfected or sterilized medical
equipment and reusable devices.
Hand washing and sanitizing: These procedures outline when, where,
and how providers should wash their hands and help reduce the spread
of infection, targeting one of the most significant areas of patient
harm.

77. Behavior Two: Speak Up When You Have Concerns
There are several ways you can “speak up,” which can enhance
the safety of the organization in which you work.
Identify and report issues with policies and procedures. If a
policy or procedure is not available, workable, intelligible, or
correct, you should report it. As previously mentioned, working
around issues with policies and procedures does nothing to help
you protect your patients.
Report unsafe working conditions, close calls, and adverse
events.— organizations that consistently perform complex
procedures safely and without error — that within these
organizations staff members report errors, elaborate
experiences regarding near misses to learn from them, and
treat any lapse in performance as a symptom that something
might be wrong with their system. They recognize that small
errors can quickly lead to big ones, and when people’s lives are
at stake, waiting for “big ones” can be too late.

78. Verbalize concerns
Perhaps the most difficult part of “speaking up” is doing it
when it matters most.
If you see another member of the health care team do
something that puts the patient’s safety at risk, you must
speak up.
-In most cases, patients do not feel like they have a voice, or
are not able to detect an impending catastrophe.
- Without you, a patient may have no voice. Think about what
you would want if you were in his or her shoes, and then do
the right thing.

79. Behavior Three: Communicate Clearly
If there were one aspect of health care
delivery an organization could work on that
would have the greatest impact on patient
safety, it would be improving the
effectiveness of communication on all levels —
written, oral, electronic
. Between 1995 and 1996, a breakdown in
communication was the number one root cause of
sentinel events reported to the Joint Commission in the
United States

80. Listen to Your Patients
Your patients know their bodies better than anyone.
Whether asking about the reason for their visit, taking a
history and physical, or probing to understand their
values and expectations regarding a variety of treatment
choices, listening to your patients is a critical activity —
possibly the most critical — that you can do to preserve
their safety.
Check for Understanding
Our health care lingo is complex, and many of our
patients have challenges with health care literacy. Don’t
let their misunderstanding of your conversation with
them place them in harm’s way. Ask them to summarize
in their own words what their condition is, what actions
they must take to manage their care, and why those
actions are important.

81. Use SBAR
SBAR is a structured communication technique
developed by, Doug Bonacum. While serving on a US
Navy submarine, Bonacum was taught how to
structure information so that even a junior team
member could easily share critical information with
someone higher, ensuring prompt action.
- Later in his career, as he listened to doctors and
nurses express trouble sharing and understanding key
facts about patients, he realized the military briefing
techniques he had learned could be modified and
applied to health care. Within this technique:
S stands for “Situation”
B stands for “Background”
A stands for “Assessment”
R stands for “Recommendation”

82. SBAR is especially useful when you’re trying to
communicate a complex set of facts so that the listener
can make a decision.
Consider the following interchange between a doctor and
nurse using SBAR.
Nurse Smith: Good morning, Doctor Adams. This is Amy Smith.
Doctor Adams: Good morning, Ms. Smith. What can I do for you?
Nurse Smith:
Situation: I am calling about Mr. Gutierrez in Room 303. His breathing has
become increasingly labored over the last four hours, and he is now quite
short of breath.

83. Background: Mr. Gutierrez is post-operative Day 3 from
a hip replacement. He has a history of hypertension and
congestive heart failure. He was doing well until today
— both eating wise and working with physical therapy.
Now his respiratory rate is 26, and his oxygen saturation
is 93 percent. I am concerned, of course, about both of
these. His lungs are crackly and he has taken in about a
liter-and-a-half more fluid than he’s discharged.
Assessment: My assessment is that he is fluid
overloaded.
Recommendation: I’d like to Hep Lock his IV (Note to
student: Generally, a saline lock is used for lines in the
arm, but it is sometimes referred to as a "Hep Lock" for
historical reasons) and have you evaluate him as soon as
possible. When can you come?
Doctor Adams: I am on my way. You should expect me in
Room 303 to evaluate Mr. Gutierrez in 15 minutes.

84. Provide Read Backs
Can you imagine an air traffic controller telling a pilot
the name and number of the runway on which to land
and not requiring the pilot to read back the name and
number of the runway?
Neither can we!
Even restaurants practice read back with take-out
orders.
Read back should be used more prominently in health
care. Write down and read back all verbal orders you
receive to keep your patients safe!

85. Behavior Four: Don’t Let Yourself or Others
Get Careless
Unless everyone in health care is willing to confront everyone else on
every single rule violation, the risk of an adverse event will always be
high.
Most violations are not done with the intent to harm, but rather with
the intent to get one’s job done, and without a thorough understanding
of the potential consequences of the behavior.
Because an individual can exhibit at-risk behavior at any time, every
provider — including YOU — must be responsible for the quality of the
behavioral choices he or she makes. In addition, to protect our patients,
every provider needs to appropriately confront “drift” — a slow,
incremental move away from safe actions — when he or she sees it in
other members of the health care team.

86. Behavior Five: Take Care of Yourself
Have you ever gone to work when you were exhausted, feeling
ill, or anxious about something?
Of course, we all have done that and probably make a regular
habit of it.
However, going to work when you are not feeling your best can
lead to patient harm. For example, it has been shown that
cognitive performance after 24 hours without sleep is
equivalent to performing with a blood alcohol level of 0.10.
Stress can also degrade performance. Current research seems
to indicate that stress may have its biggest negative effect on
knowledge-based workers — that’s probably you! Stress is also a
likely contributor toward tunnel vision, where one has an
extremely narrow focus and loses sight of the bigger picture.

87. Let s think about it ….
Which of these is an example of using a systems-based
approach to decrease the likelihood of unsafe acts?
a) Implementing a system allowing nurses to report bad
behaviors by physicians
b) Posting the names of people who have violated the
hand hygiene protocol in the break room
c) Developing a system where a new nurse in the
emergency department is always paired with an
experienced nurse who has proven to be an effective
mentor
d) Sending warning letters to pharmacists who misfill
prescriptions

88. 1) Which of these is an example of using a systems-based
approach to decrease the likelihood of unsafe acts?
Correct Answer:c) Developing a system where a new
nurse in the emergency department is always paired
with an experienced nurse who has proven to be an
effective mentor
Reporting bad behavior, monitoring hand washing, and
sending warning letters may all be important safety
processes in some cases. However, these processes are
centered around individual behavior, and they do not
address systems issues that may contribute to the
likelihood of unsafe acts. Developing a system to pair
novice and experienced nurses does recognize that
system design can help improve outcomes.

89. After a team training system is implemented in an
operating room (OR), a junior circulating nurse notices
that a particular anesthesiologist goes missing from the
OR at odd times, often seems sluggish, and occasionally
slurs her words. Concerned that the physician might be
impaired due to medication abuse, the nurse ponders
what to do next.
4) What would be the most appropriate way for him to
respond?
a) Call the physician at home and warn her to stop
abusing prescription medication
b) Refuse to work with that physician in the future
c) Talk to the medical director in confidence
d) Warn his friends about working with that physician
e) Start a rumor about the physician

90. What would be the most appropriate way for him to
respond?
Correct Answer:c) Talk to the medical director in
confidence
The junior nurse should speak up now that he has a
concern. Warning friends or refusing to work with this
physician does not improve the situation for the entire
hospital; nor does it protect the patients of this doctor.
Speaking with the medical director or another person in
authority is the best option in this difficult situation.

91. 1) Errors always result in harm.
a) True
b) False

92. 1) Errors always result in harm.
Correct Answer :b) False

93. What is a systems approach to addressing error?
a) Recognizing that the design of systems and
processes, not individuals, are the major reason for
error
b) Catching an error before it causes harm
c) Using systems to identify errors

94. What is a systems approach to
addressing error?
Correct Answer :a) Recognizing that
the design of systems and processes,
not individuals, are the major
reason for error

95. It is the highest form of self-respect to admit
our errors and mistakes and make amends for
them.
To make a mistake is only an error in
judgment, but to adhere to it when it is
discovered shows infirmity of character.
Dale turner