You may notice that I'm wearing a scrub shirt today, rather than a white coat. And I'm wearing this shirt to emphasize the fact that error proofing needs to take place on the front lines and not in the conference room or the office. These improvements require active involvement of those who are directly caring for patients to create the solutions. I would like to start with the story of Mary McClinton. She was a 69 year old social worker, the mother of 4 loving sons, serves as a foster mother for 8 children, was a teacher at her church school and had adopted an Eskimo tribe in Southeastern Alaska to help their disadvantaged children. She was a mother to everyone. In 2004 she was undergoing an angiogram at Virginia Mason Medical Center, to investigate a brain aneurysm. Two clear liquids were present in unlabeled bottles in the procedure room. One containing chlorhexidine for a skin decontamination, they had previously used a brown iodine prep for the skin, and the other containing the angiogram radiopaque dye. Chlorhexidine was mistakenly injected into her bloodstream rather than the contrast dye, leading to her death. Was this a human mistake or a systems error? Would anyone under the same conditions make this same mistake? I think the answer would be yes. Did anyone prior to Mary McClinton experience a near miss? It is not clear if others at Virginia Mason had experienced a near miss. However, after the case was shared with Seattle and the world, it became clear that another hospital had a similar error two years earlier and had not possessed the courage to share their mistake with the public. Should an administrator have anticipated this type of error? I think the answer is yes. Based on the answer to these three questions, it is clear this was a systems error. Following this tragic event, Virginia Mason established the annual Mary L McClinton Patient Safety Award to honor her death and remind everyone at the hospital of the importance of continually focusing on patient safety. When discussing techniques for reducing mistakes and errors, I have purposely chosen to term these efforts error proofing rather than mistake proofing, because error focuses on the system, while mistake focuses on the individual. Studies show that two-thirds of errors are due to defective system. As we emphasized in Fixing Healthcare 1.0, every system is designed to produce the outcome it achieves. When there is an error, ask the three questions we asked about Mary McClinton's case. And the majority of the time, the answers to these questions will point you toward a defective system or a system that has inadvertently created conditions that make a human error more likely. A common practice in the past was to blame the individual and in the previous half century, because our systems had been relatively simple, blaming the individual was often appropriate. However, as we discussed earlier, the present systems of delivery contain multiple steps and are highly interdependent. And this complexity greatly increases the likelihood of a systems error. How do we approach errors that lead to patient harm? Marx has created a Just Culture that establishes criteria for determining the most appropriate response to a preventable medical error. As he stated, individual practitioners should not be held accountable for system failures over which they have no control. We know that if providers are consistently punished for events that were not under their control, they will hide their mistakes, driving quality improvement underground. As Mrs. McClinton's case exemplifies, it is important to differentiate errors caused by negligence or recklessness from errors caused by defective systems and to respond accordingly. The Just Culture created by Marx describes three institutional responses. First and most common, inadvertent human error. These events can be skill based, someone lacked the skills to perform the procedure, make the proper decision or take the proper action. Or can consist of a lapse, a mental error, an omission such as forgetting a step. One common lapse is forgetting to wash your hands. Or this could be due to a slip or a commission. Turning the wrong knob or filling a syringe with the wrong fluid, as happened in Mary McClinton's case. What is the appropriate response to an inadvertent human error? Administration console the person who made the error and recruit an improvement team to quickly correct the systems defect. In the case of Mary McClinton, they eliminated the bottle of chlorhexidine and provided swabs soaked in this solution for prepping the skin. Eliminating the possibility of chlorhexidine ever being injected into a patient. The second category is at-risk-behavior. This is a choice by the individual to bypass an inspection or step in a procedure. The risk of bypassing this step is not recognized. And the risk was felt to be justified because of competing rewards, the most common motivation being to save time. One example is the nurse's use of a barcode scanner to assure the accurate administration of medications to the patient. The standard procedure is to scan the medication and then scan the patient's identification wristband. However, on occasion, when a nurse is pressed for time, he or she may take the label for the wristband and scan it and all the medications for the patient at a more convenient location, rather than at the patient's bedside. And then subsequently deliver the medications to the patient. This batching can and has led to medication errors. The appropriate response for these events is coaching, increasing incentives to do the right thing, and as we will discuss in a subsequent video, inspection, moving from level 2-4 to level 5-6 error proofing. Finally, supervisors need to increase situational awareness through discussions that encourage the providers to more deeply understand the potential consequences of their actions. Finally, the third category is reckless behavior. An individual's action demonstrates conscious disregard for known risks. These events are far less common. One example is a provider coming to work drunk. The appropriate response for these events is punishment combined with remediation or removal from the position. By creating a Just Culture, those working on the front line will be more wiling to report errors with the understanding that they will not be unjustly punished. An efficient and effective reporting system is critical because if we don't know that an error has occurred, we cannot fix it. Virginia Mason has created a three tier system. Red events represent 1% of errors. They are life threatening and require reporting to regulatory organizations. These events include falls, pressure ulcers, and toxic medication errors. Orange, 8% of errors, are less severe and include communication problems among services. And finally yellow, 91% of the errors, includes slips and latent errors, and delays in care. Another effective reporting system breaks down errors into categories. And UF Health, we use an electronic system organized by category and these categories are listed on this slide and include test variance, diagnostic variance, treatment variance, procedure variance, documentation variance, adverse drug reactions and delayed emergency response. Our system is very easy to use and a report can be completed within ten minutes. Because I am working to reduce errors in our hospital, I deeply understand the importance of reporting. However, many of those who work in healthcare do not realize how important error reporting is for improving our systems of care. They feel that their reports will not make a difference. I can speak from personal experience that our quality department acts quickly on each report and I truly feel my reporting does make a difference. How can we encourage others to report? Using the campaign methods described in our earlier course may be helpful. Identify physicians and nurse champions using one on one meetings, consider a forum where reporting is discussed, remember to include personal narrative to touch the heart, to change the mind, to encourage action. Slogans and posters can also be helpful. Whenever possible the quality department should provide feedback and rewards for those who report errors. Remember, ignoring errors assures that other patients and providers will experience the same problem. Near misses also need to reported. In a highly reliable organization, everyone is fixated on preventing errors. Remember Mary McClinton. The lives of our patients hang in the balance. Thank you.
