1 gerald b. hickson, md faap associate dean for clinical affairs associate dean for clinical affairs...

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Gerald B. Hickson, MD FAAPGerald B. Hickson, MD FAAP

Associate Dean for Clinical AffairsAssociate Dean for Clinical AffairsDirector Center for Patient and Professional AdvocacyDirector Center for Patient and Professional Advocacy

gerald.hickson@vanderbilt.edugerald.hickson@vanderbilt.edu

Vanderbilt University Medical CenterVanderbilt University Medical Center*With a little help from Louis Grizzard

Errors in Medical Practice

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What did I just hear?

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What Did I Just Hear??• You: experienced L&D RN, caring for

CI, 28 y/o primagravida. • SROM at 0800, completely dilated by

1030. CI pushed for 3½ hours, C/S w/o difficulty for CPD. Infant to nl nursery. Est. blood loss = 600 ccs.

• First 2 hrs post delivery “normal” including unremarkable vitals, good pain control with PCA pump.

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What Did I Just Hear??• CI developed sudden vag bleeding, OB

paged. Given Methergine IM + uterine massage. Vag exam revealed handful of large clots. Blood loss ~ 1000 ccs.

• OB left CI to tend to other pt. Over next 30 min you changed bed linens 3 times due to blood loss, CI began to complain of low back pain, cold hands and feet.

• You page OB again. A CBC ordered earlier indicated that CI’s Hgb had fallen from 14.1 to 6.4.

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What Did I Just Hear??

• OB ordered 1 unit PRBCs, left to attend other pt. While blood was infusing CI became more tachycardic, BP=82/22. You started 2nd IV, called for OB & Anesth. When Anesth arrived CI said she felt light headed.

• When the OB arrived Anesth still at bed-side. OB seemed irritated.

• Vigorous discussion ensued in CI spouse’s presence.

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What Did I Just Hear??

• Anesthiology asserted CI was bleeding out, needed stat surgery. OB insisted “long differential, including a PE.”

• OB ordered 4 Units PRBCs. Anesth: “You don’t treat PE with blood.”

• CI arrested, CPR initiated. Code team was present. You escorted husband to private waiting room. He has several questions.

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Spouse’s Questions

• Is my wife going to be okay?

• What are they doing/going to do?

• Were they arguing about what to do?

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Spouse’s Questions

• What did I just hear? Were they arguing about what to do?

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Were they arguing? Why might RN choose/not choose:1. “Gosh, I was so busy, I didn’t hear…”

2. “This is a critical situation…who can I call to help support you?” (redirect)

3. “Doctors have different approaches and discuss them this way, but not usually in public…”

4. “This is something we’ll want to take up with Dr. OB...”

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5. “We’re trying to stabilize her, let me go find out and I’ll come back to share…”

6. “Doctors doing all they can… discussing different possibilities, addressing them all…I will ask one to talk with you…”

7. To provide her/his own diagnosis8. To reflect her/his concerns about the

care provided so far by the doctor(s)And what might be the follow-up questions?

Were they arguing? Why might RN choose/not choose:

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Adverse Events and Negligent Med. Injuries

Negligent injuries(1-2% of stays)

All U.S. hospital stays

Sources: Mills et al. (1977), Brennan et al. (1991), IOM (1999).

Adverse events(6% of stays)

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Reasons: Definition of Error*

“occasion in which a planned sequence of mental or physical

activities fails to achieve its intended outcome.”

*Human error. NY: Cambridge Press, 1990.

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Errors in MedicineRasmussen and Jenson described performance based on concept of cognition.

They classify performance:1) skill-based (schema)2) rule-based (if x, then y)3) knowledge-based (synthetic

thought) Erogonomic 1974; 17:293

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Lessons - Cognitive Psychology

Skill-based control schema (linked sequences direct routines)

triggers: choice, enviro., circumstances

processing and behaviors are automatic (quick, efficient, untaxing)

expert on limited #’s of activities: specialists vs. generalists Reason, J. , 1992 Human Error

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Skill-based Errors: Slips

• Slips - breaks in automatic routines - attention diverted • loss of activation

- pre-occupation or interruption. • description error: right action/wrong target - is it cream/soap? • associative activation - answer phone when doorbell rings. • capture: less familiar by more familiar Reason, J. , 1992 Human Error

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Lessons – Cognitive Psychology

Rule-based control

• May be based on EBM (epiglottitis)

• May be based on consensus (bilirubin)

• Often used to deal with uncertainty (febrile, neonate)

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Rule-based Errors

• Situation incorrectly perceived-wrong rule.

• Rules have a life of their own – once applied… • Discrepant information doesn’t provoke reconsideration.

• Rules may create a false security.

Reason, J. , 1992 Human Error

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Cause-Effect Diagram

“Ichikawa Diagram”

People Procedure Equipment

Environment Policy Other

Adverse Outcome

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Causes Associated with Adverse Events

0 5 10 15 20 25 30 35 40

Communication

Medication

Treatment

Diagnosis

IV Issues

Patient Behavior

Equipment

Administration

Surgery Related

Resident Supervision

Documentation1996-2001 Pediatrics (n=116)

Confidential and privileged pursuant to TCA section 63-6-219

Number of Cases

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Types of Communication Breakdown

0 4 8 12 16 20

Makes family unhappy

Among care givers inside VUMC

Between patient and caregiver

Among care givers outside VUMC

Jousting among physicians

Pt not informed of event, found out

Inadequate discharge instruction

Confidential and privileged pursuant to TCA section 63-6-219

1996-2001

Number of Cases

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Selected Comparative Results(% Cases Including Cause Categories)

Department/DivisionCategory 1 2 3 4 5

Dx/Tx 91% 48% 59% 43% 37%

Communic 35 55 59 30 32

Admin/HR 14 20 28 21 13

Res Superv 7 25 20 29 4

$ Loss Comparisons 3.7 1.3 5.0 .27 1.0(expressed as multiples of 5 experience)

Confidential and privileged pursuant to TCA section 63-6-219

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Basic Chain of Command Communication Principles

1. In emergencies, pts always come first

2. Target communications carefully

3. Think about the person you’re calling and their motivations

4. State exactly what you want to achieve

5. Maintain credibility

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Basic Chain of Command Communication Principles

6. Know pros and cons of how you choose to phrase your main message

7. Make communications two-sided

8. Ask questions to promote engagement

9. Clarify the conclusion(s) you reach

10.Be accountable, promote accountability

11.Others?

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Your Comments and Questions

Now or Later

www.mc.vanderbilt.edu/cppa