Learning from Adverse Events

With a 30 year career in healthcare, largely with a bend toward preventing harm coming to patients, I thought it was rather odd, when on February 24, 2011, I found myself arranging a transfer of my 76 year old father to the tertiary referral center ER that I worked in following failed treatment at a capable community hospital.  He arrived in Septic Shock.  Within a few hours we knew something that the community hospital knew 5 days earlier but had failed to share.  My dad had MSSA.  Methicillin-Sensitive Staphylococcus Aureus.  Not the bad kind of staph.  The good kind that responds to antibiotics.  But a series of broken systems prevented a phonecall from being made to my family advising that immediate antibiotic therapy was warranted, and in his case, since a painful replaced knee joint had brought him to the ER, a surgical washout was indicated.  Despite an immediate surgical washout of all of his joints and aggressive antibiotic therapy, he died within 2 weeks of multi-system organ failure.  My dad, a preventable death, that one would hope has led to significant system changes to prevent that type of error from occurring again. 

Since 2001, it has been known that safety systems in hospitals ranked right up there with bungee jumping, extreme mountain climbing, and motor cycle racing (Amalberti 2001).  We tend not to think that our life is taken into our hands when being cared for in hospitals but remain cautious about ultrasafe systems such as scheduled airlines and nuclear power.  Hospitals have inherent dangers of complicated technical equipment, extremely sick patients, infection sources, a hurried staff, delays in treatment, unclear orders, and mislabeled specimens (The Advisory Board Company (2005).  We forget that even small chances of error add up to high numbers of adverse events every year.

Efforts have been underway since the mid 2000's to address the feared 100,000 lives being lost at the cost of preventable medical errors.  Hospitals have now started focusing for example on holding physicians and nurses responsible for handwashing.  Something Florence Nightingale published in 1915.  Change is not coming easy to gain compliance.  Health care workers are subject to the same resistance to change that all adult workers are.  To make matters worse, 100,000 lives was a low number.  "The death toll from health-care screwups adds up to at least 500,000 Americans annually.  That is the equivalent of more than three jumbo jets crashing every day of the year." (2012, Graedon)

Health care workers do tend to be high achievers and pay attention to data, especially when it is drilled down to their own data.  We can learn from Adverse Events.  Here is a top 10 list....

1. Investigate fully all adverse events - identify the etiology of serious medical events.  This is the first step in eliminating mishaps.
2. Look for trends.  Time of day, provider/nurse/ unit specific data should be analyzed.
3. Prepare cause & effect diagrams (fishbone diagrams) involving people involved in the event

4.  Study and address root causes ( look at day and time, categorize common causes,
5.  Study impact of patient behavior (intoxication, mental illness, anger)
6.  Look for communication errors  (blood culture results!)
7.  Keep emphasis on quality improvement, not blaming.
8.  Widely disseminate findings, where you cannot share case results, provide general education.
9.  There is no margin of error that is acceptable.
10.  Your staff does not GET THIS...until you make it personal.  Here is my dad...

10 WAYS PATIENTS CAN PREVENT MEDICAL ERRORS (From:  (2012) Graedon, J. and Graedon, T.  Top Screwups Doctors Make and How to Avoid Them.

1. Expect mistakes and have an advocate with you in the hospital.
2. Check every medicine.  Make sure the dose is right.
3. Be assertive.  "Being nice can get you killed."
4. When in doubt, say no.  Demand an explanation.
5. Be vigilant during transitions, from one floor to another, or when shifts change.  Handoffs in care are risky.
6. Alert the nurse or "rapid response team" if something seems wrong.
7. When discharged from the hospital, get detailed instructions and contact information.  Know what symptoms might signal a worsening situation or infection.
8. Hospital doctors may never speak to your primary physician.  Take your records and don't assume doctors already know what's in them.
9. Double check everything.  Don't assume no news is good news or that test results are always correct.  If something seems wrong, request a repeat.
10. Take a friend or family member to doctor's visits.  Nearly every error made in the hospital can also be made in the outpatient setting.  A second pair of eyes and ears can be very useful in getting instructions and spotting problems.

An Infection, Unnoticed, Turns Unstoppable: The Story of Rory Staunton