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Medical Errors

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7 views

Medical Errors

Uploaded by

cataliao05
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Medical Errors

Prepared by Dr. Aliaa Ghies Ibrahim


MD, Dip. PM, FISQua, CPPS
Presented by : Dr. Azza Farouk
Errors definition
An adverse event or near miss that is preventable with the
current state of medical
Knowledge.
An act of commission (doing something wrong) or omission
(failing to do the right thing) that leads to an undesirable
outcome or significant potential for such an outcome.

2
Errors definition
The failure of a planned action to be completed as intended
(an error of execution) or the use of a wrong plan to achieve
an aim (an error of planning)

Institute of Medicine (IOM), 1999


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Burden of the
Medical Errors
o Direct:
• Patient.
• Family.
• Job.
• Health Care Provider.
o Indirect cost
• Health system
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Types of
Medical Errors
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1.
Surgical Errors
Surgical Errors
• Anesthesia-related safety
complications.
• Wrong-site/wrong-patient
surgeries.
• Retained foreign objects.
• Surgical fires.
• Post surgical complications

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2.
Medications Errors
Prescribing errors

Transcribing errors

Preparing errors

Medications Dispensing errors

Errors Administration errors

Monitoring errors

Documentation errors
3.
Diagnostic Errors
Diagnostic Errors

•Missed diagnoses.
•Wrong diagnoses.
•Over diagnosis.

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4.
Transition and
Handoff Errors/Teamwork And
Communication Errors
• Site-to-site
Handoff
• Person-to-person

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Handoff And
Communication Errors

• Uncommunicated critical
results.
• Uncommunicated
information.
• Unstructured
telephone/verbal orders
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5.
Healthcare-
Associated Infections
Surgical site infections.

Ventilator-associated pneumonia.

Healthcare- Central line-associated bloodstream infections.


Associated
Catheter-associated urinary tract infections.
Infections
Methicillin-resistant s. aureus infection.

C. difficile infection
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6.
OTHER COMPLICATIONS
OF HEALTHCARE
Venous thromboembolism.
OTHER
COMPLICA- Pressure ulcers.
TIONS
OF Falls.
HEALTHCARE Delirium.
Causes of Medical Errors

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System.

Organization and management.

Work environment.
Causes of
Team.
Medical Errors
Individual staff member.

Task.

Patient.
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Communication
during handover
Communication during handover
• It is a real-time process of passing patient-
specific information from one caregiver to
another or from one team of caregivers to
another for the purpose of ensuring the
continuity and safety of the patient’s care.
• In a systematic review of 38 studies, poor
communication can lead to errors, patient
harm, discontinuity of care, inefficient use of
resources, and dissatisfied patients.
• In a ten years follow up study, poor hand-offs
contributed to nearly 80% of adverse events

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Hand over may take place many times during
patient journey like

• Admitting patient from ED to ward/unite of


care
• Between different shifts
• Transferring the patient to: higher/lower level
of care , diagnostic procedure or therapeutic
intervention, another facility or home discharge

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To assure the
continuity of care
through effective
communication

1. Use a standardized process/tool for provider-to-


provider hand-off
2. Dedicate a standardized place and time (without
distraction)for the hand-off.
3. Assure face-to-face communication within hand-off
process.
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The most known Communication Tools in
healthcare
• Closing the loop
• Cus
• Read-back
• Sbar
• Handoff “I pass the batton”
• Checklists
• Daily event reports
• Briefing
• Debriefing
• Visual tools like dash board 27
Closed-loop Technique

• Initiates clear, RECEIVER • Paraphrases SENDER


brief, timely, and • Perception
complete checks
message • Quietly and • Listens
attentively • Asks Clarifying
Question • Confirms,
accepts message Simplifies, or
Clarifies
SENDER RECEIVER

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Characteristics of Massage for Effective
Communication
Complete

Timely Effective Communication Clear

Brief

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CUS technique

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CUS technique
1- “I am concerned” or “I need clarity.” This is
equivalent to a red flag going up.
2- “I am uncomfortable.” The red flag is
waving.
3- “Stop.” This indicates a safety issue. This is
the extreme. If the problem reaches this
point and nothing changes, there should be a
plan for the next step in this situation.

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Barriers to Speaking Up

Fear of : Thinking that:


• Being embarrassed
• “They won’t listen anyway.”
• Feeling stupid
• “It’s not that important.”
• Being ridiculed
• Being yelled at
• Being wrong
• Saying something that’s not
important 32
Teach – back
Repeating back important information (read-back)
is thought to enhance the effectiveness of
communication.
It’s used mainly in verbal communication between
health care providers or between health care
provider and patient (repeat back from receiver to
who make the order-from lower to higher
authority - to ensure that order is right and
understood )
ISOBAR
Communication
To be used when 2 or more
people share responsibility
for a patient.

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Example of
ISOBAR being
used in a phone
call between a
nurse and a •“Dr. Jones, this is Deb McDonald RN,
physician: I’m calling form ABC hospital about
your patient Jane
Smith.”[Identification]

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• “Mrs.Smith is having increasing dyspnea and
is complaining of chest pain [Situation].
• About two hours ago she began complaining
of chest pain.
• Her pulse is 120 and her BP is 128 over 54.
She is restless and short of
breath[Observation]
• She had a total knee replacement two days
ago, no chronic illness [Background].

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• My assessment of the situation is that she
may be having a cardiac event or
pulmonary embolism we may start her on
O2 stat[Agreed plan- Assessment].
• Can you I recommend that you see her
immediately. Do you agree? [Readback-
Recommendation]”

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• Medical handovers must occur
either face to face or via
telephone(Some cases).
• All handovers should be
supported by current, appropriate
documentation (clinical notes, test
results, appointment schedules etc.
“Only a relationship bonded by
understanding and respect can
deepen into a true healing
partnership.”

Bernard Lown, M.D.


The Lost Art of Healing
THANKS!
Any questions?

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