Error Identification

There are three methods of error identification:

Mandatory reporting

Voluntary reporting

Active surveillance systems

Mandatory reporting

In most organizations where mandatory reporting exists, a regulatory agency or governmental body mandates reporting of errors resulting in significant injury.

These errors are discoverable by clinical audit (allowing enforcement), and they are the types of errors for which punitive action can be taken.

This type of reporting satisfies the “public’s right to know”

Voluntary Reporting

Voluntary error reporting systems are usually used to identify “latent” errors.

In most organizations these systems are confidential (and sometime anonymous), and they often confer immunity from penalty.

Non-punitive and confidential systems tend to have high compliance rate.

Voluntary Reporting

The aviation safety reporting system has received and saved more than 500,000 voluntary reports of near-misses.

Active Surveillance

Active surveillance is the identification of error through observation. This can be:

Direct observation while providing care (observers watching clinicians “in action”) or

Indirect through chart review, or observation of error markers ( abnormal drug levels in serum as a medication dosage error marker)



How should medicine evolve to reduce medical error?

Use Information technology to reduce medication error

Reducing reliance on memory and vigilance

Report errors for peer review

Required autopsies for hospital deaths

Mandatory “M&M” conferences

Use “M&M” conferences to accomplish real QA and QI

How should medicine evolve to reduce medical error?

Push outcomes research efforts

Sharing of data and improving communication

Development of “best practice” guidelines based on medical evidence

Eliminate the “culture of blame”

Standardizing processes

Improving physical feature of the workplace





Process auditing

“Process auditing” is the systematic ongoing evaluation of facilities and procedures

Process auditing involves anticipating where breakdown may occur and where barriers and defenses against mishap are weakest- the “what it” point of view

Performance monitoring

Performance monitoring is one technique to detect “near- miss” behavior before a patient has actually been injured

Sentinel event

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.

The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

Such events are called "sentinel" because they signal the need for immediate investigation and response



"All sentinel events are the result of human errors that queue up in a particular sequence."



Sentinel event watch

When a sentinel event occurs in a health care organization, it is necessary that :

appropriate individuals within the organization be aware of the event;

investigate and understand the causes that underlie the event;

make changes in the organization’s systems and processes to reduce the probability of such an event in the future.

Sentinel event watch

The leaders are responsible for :

establishing processes for the identification,

reporting,

analysis,

prevention of sentinel events

ensuring the consistent and effective implementation of a mechanism to accomplish these activities

Sentinel event watch phases

Identification of the errors that occur.

Analysis of each error to determine the underlying factors -- the "root causes" -- that, if eliminated, could reduce the risk of similar errors in the future.

Compilation of data about error frequency and type and the root causes of these errors.

Dissemination of information about these errors and their root causes to permit health care organizations, where appropriate, to redesign their systems and processes to reduce the risk of future errors.

Periodic assessment of the effectiveness of the efforts taken to reduce the risk of errors.





"Errors must be accepted as evidence of systems flaws, not character flaws"



(Leape, 1997)