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How to eliminate medical Errors Gary L. Roth, D.O., FACOS, FCCM, FACS
Medical Director, Keystone Center for Patient Safety
Sam R. Watson, MSA, CPPS Execu&ve Director, MHA Keystone Center How to eliminate pa;ent Harm through Awareness Gary L. Roth, D.O., FACOS, FCCM, FACS
Medical Director, Keystone Center for Patient Safety
Sam R. Watson, MSA, CPPS Execu&ve Director, MHA Keystone Center Where is the handout? [email protected] Objec&ves A?endees will: •  Accept that healthcare is a high risk industry. •  Understand the key concepts of high reliability. •  Understand the levels of error preven&on. •  Understand the factors to mi&gate error. •  Understand how recogni&on and par&cipa&on in collabora&ve ini&a&ves will reduce the risks of medical errors. •  Develop an improved awareness of risk-‐
management in the ambulatory (out-‐pa&ent) seMng System Safety in Evolu&on Accident Model Linear Model (Single Root Cause) Epidemiological Model (Mul;ple latent factors) Systemic Model (Emergent variability) System Complexity Era of resilience Era of socio-‐
technical interac;ons Era of human The issue is errors Era of The issue is improper socio-‐
technology technical The issues are individual human interac&ons performance. hardware failures 1960 1980 2000 Source: K. Furuta, Resilience Engineering Research Center The issue is vulnerability against unan&cipated situa&ons. From Checklists to Resiliency and High Reliability HRO – High Reliability Organiza&on •  “Fewer than normal accidents” •  “Mindfulness” •  HRO Roots of Theory: –  Culture change decreases accidents (Safety Culture) –  ShiV from percep&on that organiza&on is “ra&onal machine” to “an arena in which complex organiza&onal processes occur.” Source: Chassin, MR, Loeb, JM. The Milbank Quarterly, Vol.91, No. 3, 2013 (pp. 459-‐490). Five Principles of High Reliability Organiza&ons 1.  Preoccupa&on with failure 2.  Reluctance to simplify interpreta&on 3.  Sensi&vity to opera&ons 4.  Commitment to resilience 5.  Deference to exper&se Source: Chassin, MR, Loeb, JM. The Milbank Quarterly, Vol.91, No. 3, 2013 (pp. 459-‐490). Implementa&on Process Ø  An;cipa;on: prepare for long-‐term threats and changes Ø  Monitoring: watch for system states and ﬁnd out clues to threats Ø  Responding: take immediate ac&ons to regulate func&on variability Ø  Learning: learn from good as well as bad outcomes Source: K. Furuta, Resilience Engineering Research Center Now it’s my turn D.O. to D.O. AMtudes and Beliefs •  If I exercise suﬃcient professional judgment and cau&on my pa&ents’ care will be safe. •  Mistakes occur because staﬀ are careless, fa&gued, or too busy. •  Professionals need to use judgment about when to follow or ignore policies. •  An experienced person is less likely to make an error. •  I am careful. AMtudes and Beliefs •  If I exercise suﬃcient professional judgment and cau&on my pa&ents’ care will be safe. •  Mistakes occur because staﬀ are careless, fa&gued, or too busy. •  Professionals need to use judgment about when to follow or ignore policies. •  An experienced person is less likely to make an error. •  I am careful. How to avoid medical errors? •  You cannot – errors are “normal” •  You can avoid Harm! •  Complexity of healthcare today is staggering •  Errors will happen •  Everyone errors everyday •  We get distracted •  We are Human •  Most errors do not lead to harm •  An Error can be a strong signal that there are major systems problems that allowed the error to occur •  Fallibility is part of the human condi&on •  We can’t change the human condi&on •  We can change the condi&ons under which humans work James Reason Just Words… Deﬁni&ons •  Error –  the failure of a planned ac1on to be completed as intended (i.e., error of execu1on) –  the use of a wrong plan to achieve an aim (i.e., error of planning) Deﬁni&ons •  Adverse Event –  Injury caused by medical management rather than the underlying condi&on of the pa&ent. •  Preventable Adverse Event –  Adverse Event a?ributable to error •  Negligent adverse event –  The care provided failed to meet the standard of care reasonably expected of an average physician qualiﬁed to take care of the pa&ent Swiss Cheese Model Due to alignment of gaps in our current process, in spite of the fact that the process
was in full compliance with prevailing relevant standards, an adverse event occurred
Triggers Adverse Event Safety deﬁni&on •  Absence of errors •  Freedom from accidental injury •  Safe environment = low risk of accidents –  reduce defects in the process or departures from the way things should have been done –  establish opera&onal systems and processes that increase the reliability of pa&ent care. “Culture” of Safety deﬁni&on • 
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It’s like ‘air’ Eﬀec&ve teamwork An environment of trust and accountability Where we all can speak-‐up Repor&ng is the norm –  Errors and Near Misses are reported –  In a &mely basis •  Repor&ng is encouraged and rewarded –  Leadership supported –  Leadership involved •  Lack of an op&mal safety culture allows unsafe behaviors / condi&ons to be present “Culture” •  You don’t: –  Teach it –  Mandate it –  Regulate it •  You do: –  Foster it –  Set the stage –  Show it in what you do – by example –  “Plant the seed for it to grow & ﬂourish Culture “Culture is what people do when no is looking.” –  Herb Kellejer, Chairman Southwest Airlines Modern Quality Movement •  Decade of research •  Ins;tute of Medicine December 1999 •  44,000-‐98,000 Americans die in hospitals each year as the result of preventable medical errors. Ins&tute of Medicine: To Err is Human Findings •  Errors are oVen unrecognized, chronically under-‐reported •  Medical errors are frequent and lethal (44,000-‐98,000 deaths/year) •  7,000 deaths from medica;on errors alone Ins&tute of Medicine: To Err is Human Key Messages •  Systems are primarily at fault •  Not individual competence •  In Medicine there has been inadequate a?en&on to systems design (compared to avia&on, nuclear power) •  Human factors research indicates educa&on in itself is an ineﬀec&ve method to change behavior •  Requires a change in Culture •  Our healthcare system is an&quated with respect to safety History Lesson In 1925, 4 main types of adverse events iden&ﬁed for hospitalized pa&ents: •  Burns due to hot water •  Delirious pa&ents jumping from hospital windows •  Accidents connected with hospital elevators •  Mistakes in the use of drugs Aikens
C. Study in the Ethics for Nurses. Philadelphia: Saunders; 1925
Where are the risks today? •  Those undergoing cardiothoracic surgery, vascular surgery, or neurosurgery •  Those with complex condi&ons •  Those in the emergency room •  Those looked aVer by inexperienced doctors •  Older pa&ents •  Medica;on errors Where do we stand? Life Expectancy at Age 65 Female
25
20
23.0
18.0
21.3
16.9
21.0
17.6
20.6
17.2
20.0
Male
19.6
16.7
16.1
19.6
19.5
19.1
16.6
16.0
16.1
15
10
5
0
Source: The Commonwealth Fund, calculated from OECD Health Data, 2005.
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Infant Mortality Rate Infant deaths per 1,000 live births 10
International variation
7.0
5.0
5
4.1
3.0
3.0
3.3
4.1
4.1
4.2
4.2
4.4
4.4
4.5
5.0
5.0
5.0
5.1
5.2
5.4
5.6
4.5
3.5
2.2
0
*2001.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. Data: 2002 rates International
estimates—OECD Health Data 2005; State estimates—National Vital Statistics System, Linked Birth and Infant Death Data
(AHRQ 2005a).
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Deaths Due to Surgical or Medical Mishaps per 100,000 Popula&on 0.8
0.7
0.7
0.6
0.6
0.5
0.5
0.5
0.5
0.4
0.4
0.4
0.3
0.2
0.2
0.2
0.1
0.0
b
United
States
b
Germany
Canada
b
France
b
United
Kingdom
b
Australia
a
OECD
Median
Japan
Netherlands
a2003
b2002
Source: The Commonwealth Fund, 2004 data calculated from OECD Health Data 2006.
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Health Care Spending per Capita Adjusted for Differences in Cost of Living
8000
$7,290
7000
6000
5000
4000
$3,895
$3,357
$3,601
$3,837
$3,588
$2,992
3000
$2,581
$2,454
2000
1000
0
Australia
Canada
France
Germany
Japan*
Netherlands New Zealand
Source: OECD Health Data 2009
* Japan data for 2006
Source: The Commonwealth Fund, 2004 data calculated from OECD Health Data 2006.
United
Kingdom
United States
32
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Paradox of Plenty – I say to you… •  Most advanced healthcare system in the world
•  Highest Cost for the Lowest Quality
•  For the money the United States spends on
healthcare, about $2.5 trillion a year – the quality of
care is unacceptably low
•  Each year as many as 15 million patients harmed in
some manner by America’s healthcare system
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Where is the risk? Heart Disease
Cancer
Stroke
Lung Disease
Medical Errors
Accidental Injury
Pneumonia
Diabetes
AIDS
0
200
400
600
Deaths in Thousands
Source: US Mortality Data 1997 / CDC / IOM 800
Who has the data? Those who pay for care are now wri&ng the “Quality Agenda” using data and all the “Four Le?ered Words” • 
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Value-‐based purchasing (VBP) $ Core measures $ HCAHPS $ Hospital-‐acquired Condi&ons (HACs) $ Readmission penal&es $ “Never Events” $ “Meaningful use” for IT implementa&on $ Malprac&ce Suits •  Not a surrogate of Quality •  Only the “Tip of the iceberg” regarding quality •  Does not typically include: •  Near misses •  Events with less severe outcomes Hospital 34% 21% 20% Out-‐Pa;ent Surgical Errors 23% Diagnos;c Errors 46% Treatment Errors 30% Malprac&ce Suits •  Not a surrogate of Quality •  Only the “Tip of the iceberg” regarding quality •  Does not typically include: •  Near misses •  Events with less severe outcomes Hospital 34% 21% 20% Out-‐Pa;ent Surgical Errors 23% Diagnos;c Errors 46% Treatment Errors 30% Why more out-‐pa&ent claims? •  ShiV to move pa&ents out of the hospital •  More complex pa&ents with mul&ple co-‐morbid illnesses •  Docs seeing more pa&ents for shorter &mes –  Easier to miss symptoms or miss diagnose –  900 lab results each week •  Need to coordinate care between mul&ple specialists •  Wake up call for those that prac&ce in the outpa&ent seMng Serious Reportable Events •  SREs •  Represent largely preventable errors & events •  List of 26 “serious reportable events” –  Oﬃce-‐based prac&ces –  Ambulatory surgery centers –  Skilled nursing facili&es Na&onal Quality Forum SREs • 
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Wrong-‐site surgery Pa&ent falls Serious medica&on errors Pa&ent death or serious injury from failure to follow-‐up or communicate: –  laboratory, pathology, or radiology test results •  Diagnos&c Errors -‐ 2:1 Transi&on of Care
Hand-‐oﬀs (deﬁni&on) •  A transfer and acceptance of responsibility of pa&ent care –  A real-‐&me passing of informa&on from one caregiver to another or from one team of caregivers to another –  For the purpose of ensuring the con&nuity and safety of the pa&ent's care. –  Through eﬀec&ve communica&on •  Not limited to the hospitalized pa&ent Consequences of sub-‐standard hand-‐oﬀs • 
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Delay of treatment Inappropriate treatment Adverse events Omission of care Increase hospital LOS Avoidable readmissions Increased costs Ineﬃciency from rework Other minor or major pa&ent harm The Hospital •  “The hospital is the most complex human organiza&on ever devised…” –  Peter Drucker The Perfect Storm •  Pa&ents need to be sicker than ever to get into the hospital •  Hospital lengths of stay are geMng shorter •  Pa&ents are not well when they are discharged—they are “well enough. . . .” •  Pa&ent need to understanding that par&cipa&on is key to successful health maintenance •  As a general rule, “case management” and educa&on are not recognized by the reimbursement system •  Increasing sub-‐specializa&on of care and fewer “generalists” available—especially for the Medicare popula&on 47 Types of error •  About half of the adverse events occurring among in-‐pa&ents resulted from surgery. •  Next come – Complica&ons from drug treatment – Therapeu&c mishaps – Diagnos&c errors The alphabet soup of the hospital • 
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HAI VTE CLABSI CA-‐UTI etc. Wrong site surgery •  Best es&mate = 40 per week in US •  High rates of risks introduced in 3 area –  OR: 59% of case had risks; 32% with mul&ple risks –  Pre-‐op area: 52% of cases had risks; 25% with mul&ple risks –  Scheduling: 39% of cases had risks The Joint Commission What can we do? •  Improve communica;on between physicians, pharmacists & nurses •  Ac&ve engagement of pa&ents & families •  Medica&on Reconcilia&on •  Encourage Medica&on lists •  Educate Medica&on Why focus on medica&on-‐related error? •  One of the most common types of error •  Substan&al numbers of individuals are aﬀected •  Accounts for a sizable increase in health care costs Scope of the problem •  27% of ALL prescribing errors that occur in the hospital result from incomplete medica&on histories at the &me of admission. •  22% of Discrepancies could have resulted in pa&ent harm during their hospitaliza&on. •  59% of Discrepancies could have resulted in pa&ent harm if the discrepancy had con&nued as ordered aVer discharge. Sullivan C, Gleason KM, et al. Medica;on Reconcilia;on in the Acute Care Se`ng: Opportunity and Challenge for Nursing. J Nurs Care Qual 2005 Vol 20, No2: 95-‐98 54 Evidence of Reality •  One in ﬁve general medicine pa&ents experiences an adverse event (resul&ng from medical management) within two weeks of hospital discharge •  66% of these events are adverse drug events The Incidence and Severity of Adverse Events Aﬀec&ng Pa&ents aVer Discharge from the Hospital. Forster AJ. Ann Intern Med. 2003;138:161-‐167 55 Medica&on-‐related errors – the FACTS 2008 – 3.5 Bil prescrip&ons ﬁlled & dispensed 1% error rate (35 mil) – hospital, SNFs, home Not all result in actual harm – BUT… 1,000,000 serious injuries annually 100,000 deaths annually More deaths then from auto accidents & workplace injuries combined •  Nearly all are preventable • 
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IOM –Preven&ng Media&on Injuries more Numbers: •  Dosing errors account for 37% of errors •  Drug allergies 22% •  66% during transi&ons of care –  12% at discharge •  Errors in in-‐pa&ent prescrip&on occurred in up to 67% of all cases –  Up to 60% had at least one omission error –  about 20% had an error of commission (addi&on of a drug not used pre-‐admit) •  When non-‐prescrip&on drugs were included in reconcilia&ons, the error rate was as high as 80% Medica&on errors cost money also •  In-‐pa&ent preventable medica&on errors cost $16.4 billion annually •  Out-‐pa&ent preventable medica&on errors cost $4.2 billion annually What might help? •  e-‐Prescribing (what do you think of it?) •  Bar Coding (it is not the panacea) •  Computer Physician Order Entry (CPOE) – (don’t get me started) •  Medica&on Reconcilia&on – That’s where its at! Common Barriers to Accurate Medica&on Reconcilia&on—Pa&ent Factors Health Literacy Language Barriers Current Health Status Memory impairment, psychiatric disease Pa&ent illness [intubated] Lack of Availability of Medica&on Bo?les during evalua&on •  OTCs, Vitamins and Supplements are not always considered “Medica&ons” • 
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60 Medica&on Reconcilia&on Expert Tips •  Ask speciﬁcally about OTCs, Herbals, Vitamins, and Supplements •  Record the name, number, and loca&on of the pa&ent’s pharmacy and use their info to help ensure accurate reconcilia&on •  Focus on par&cular “problem meds” like digoxin, coumadin, insulin, an&histamines to guide important follow-‐up ques&ons about diet, drug interac&ons. •  Ask the pa&ent which physician prescribes which Medica&ons 61 Medica&on Reconcilia&on Expert Tips •  Stress the importance of maintaining an accurate list of medica&ons AND request they bring that list to every interac&on they may have with ANY and EVERY physician. •  Ask about medica&ons that were recently stopped and the reason why. •  Never ever trust someone else’s history always do a primary veriﬁca&on 62 At Discharge: Pa&ents / Family / Friends should •  Know the diagnosis •  Know key tests and treatments performed •  Know what the treatment plan is [meds, appts] •  Know red ﬂag symptoms, common side-‐eﬀects, failure points. •  Know who/how to contact if something is not going well. 63 Simple, Useful Discharge Tac&cs • 
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Pa&ent-‐Friendly Discharge Form Teach-‐Back Medica&on reconcilia&on Discharge Appointments Follow-‐up Phone Calls Assess – physical, social, ﬁnancial status Code status Advise to bring medica&ons to appointment 64 MEDICATIONS LIST on “Aber Hospital Care Plan” Teach Back Process Step 1: Using simple language, explain the concept/process to the pa&ent/caregiver. Step 2: Ask the pa&ent/caregiver to repeat in his or her own words how s/he understands the concept. Step 3: Iden&fy and correct misunderstandings Step 4: Ask the pa&ent/caregiver to demonstrate understanding again to ensure the misunderstandings are corrected. Step 5: Repeat Steps 4 and 5 un&l the clinician is convinced of Comprehension. Dean Schillinger, MD Associate Professor of Clinical Medicine
University of California, San Francisco 66 Discharge Appointments •  Must have conﬁrmed next physician appointment date and &me before discharge •  Clearly established who is responsible for follow-‐up appointment •  Within 1 week is ideal –  Sooner for pa&ents with key pending tests –  Later for sophis&cated, stable pa&ents 67 Follow-‐Up Calls •  48 – 72 hours is the sweet-‐spot •  Must be a clinical call by a fairly knowledgeable person •  Caller should have access to hospital Discharge form and key informa&on •  Use Teach-‐back when making the call •  Document the results of the call in the PCP’s medical record –  Track main issues that arise and interven&ons used to ﬁx them •  Establish a clear escala&on procedure for the caller to use when he/she cannot immediately solve the issue 68 Ambulatory seMngs Out-‐pa&ent Centers • 
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Independent Centers Doctor’s oﬃces Community based clinics Ambulatory surgical centers Imaging centers •  90% of healthcare is delivered in the ambulatory environment •  We must make the most of the “In-‐pa&ent Moment” and Maximize the value of this cap&ve audience. •  Integra&on and Communica&on is key Out-‐pa&ent •  5% experience a diagnos&c error •  Failure to diagnose -‐ example –  Pneumonia –  Decompensate Heart failure –  Renal failure •  Failure to diagnose or stage cancer! –  Colorectal cancer –  Lung cancer •  Recogni&on of Interac&ng medica&ons –  Mul&ple prescribers –  Recent hospitaliza&on Out-‐pa&ent Issues •  Follow-‐up may be more diﬃcult •  Signs & symptoms may be subtle •  “ Demands of P4P may divert clinicians’ &me & a?en&on from the cri&cal area of diagnosis.” Stand-‐alone ambulatory surgery •  Are at Risk •  Do not need to adhere to the same safety controls •  Don’t receive as stringent oversight •  May be doing “minimally invasive”/
experimental (less tradi&onal) procedures •  Need to concentrate on reducing diagnos&c & treatment errors •  Doctor investors Opportunity •  Improving risk-‐management in outpa&ent seMngs is important •  Informa&on technology that promotes safer prescribing, follow-‐up of test results •  Adding benchmark measures that reward doctors for accurate diagnosis & follow-‐up •  Be?er oversight of for-‐proﬁt ambulatory surgical centers It’s about Collabora&on •  MHA Keystone Center for Pa&ent Safety & Quality •  Vision: Healthcare that is free of harm •  “Translate Evidence into Prac&ce” –  Sam Watson Keystone Intensive Care (ICU) • 
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Reduce VAP & CLABSI Improve Culture Facilitate Daily Goal Directed Rounds Sepsis Delirium Early mobility –  Working in collabora&on of Michigan Physical Therapy Associa&on Keystone Emergency Room •  Reduce LWOBS –  Lean –  Reduce by 35% •  Reducing Boarding/overcrowding and wait &mes •  Support the early treatment of sepsis Keystone Obstetrics • 
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To eliminate preventable fetal and maternal harm Keystone OB impacts nearly 80% of all births in Mich Reduc&on in early elec&ve deliveries -‐ <39 weeks (>5%) Reduce premature rates –  Tachysystole –  Cervical Maturity •  Reduce post-‐partum hemorrhage and blood transfusion •  Reduce primary C-‐sec;on rates (20-‐24%) Keystone Care Transi&ons •  Reduced readmissions by nearly 5% 2010 -‐ 2012 •  Saved nearly $98 million •  MVC – Michigan Value Collabora&ve CA-‐UTI •  CA-‐UTI – Catheter-‐associated urinary tract infec&on •  Formerly HAI •  Reduced CA-‐UTI rates by 75% 2012-‐2013 in par&cipa&ng hospitals •  Saved $12,000 Keystone Surgery •  September 2013 Consumers Report •  Eliminate surgical site infec&ons – SSI –  An&bio&cs – appropriate –  Glucose control –  Temperature control –  Clip vs Shave –  Reduc&on in SSI -‐ $252,000 from 2011 to 2012 Keystone Surgery •  Prevent defects in care – including wrong site surgery and retained foreign bodies •  Eliminate mislabeled specimens •  Improve teamwork climate –  Brieﬁng & Debrieﬁng •  Opiod u&liza&on •  MSQC -‐ complementary Hospital Engagement Network (HEN) •  Recently began the third year (began 2011) •  1 of 26 contracted by the U.S. Department of Health & Human Services •  Reduce 10 areas of preventable harm – 
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Never Events / Medical Legal ADE CA-‐UTI CLABSI Injuries from Falls and Immobility Obstetrical Adverse Events Pressure Ulcers SSI VTE VAP Avoidable readmissions Tools The conversa&on begins •  Huddles – problem solving •  Brieﬁng – planning •  Debriefs – process improvement Huddle Problem solving •  In-‐pa&ent and Out-‐pa&ent •  Hold ad hoc, “Touch-‐base” mee&ngs to regain situa&on awareness •  Discuss cri&cal issues and emerging events •  An&cipate outcomes and likely con&ngencies •  Express concerns Brieﬁng Planning •  Form/Inform the team •  Designate team roles and responsibili&es •  Establish climate and goals –  Psychological safety •  Engage team in short and long-‐term planning •  example – Pre-‐procedure Debrief •  Process Improvement •  Brief, informal informa&on exchange and feedback sessions •  Occur aVer an event or shiV •  Designed to improve teamwork skills •  Designed to improve outcomes –  What went well?
•  Celebrate! –  What did we learn? –  What should be done diﬀerent next &me? What are the Dollars & Cents? HAC and Es&mated Financial Impact Slide courtesy of The Joint Commission Healthcare-‐associated Infec&ons are an Enormous Burden on the U.S. Healthcare System Slide courtesy of The Joint Commission Bo?om line in Michigan: Interven&ons in Michigan have saved… •  Countless lives… •  $116.5 million through •  Ini&a&ves •  Collabora&on Pa&ent Safety Organiza&on (PSO) •  Cer&ﬁed under the federal Pa&ent Safety Act and is a Qualiﬁed Hospital PSO •  Allows providers to seek expert help in understanding patent safety events and preven&ng their recurrence •  Data warehouse –  Adverse events –  Near Misses •  Safe tables – a legally protected environment –  Learn from mistakes and near misses to avoid future harm –  A safe place to provide disclosure “Meaningful use” -‐ Friend or Foe?? Evidence-‐backed methods Health informa&on technology EMRs Assist management of tests – highlight abnormals •  Treatment errors iden&ﬁca&on • 
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–  Dosage errors –  Dangerous interac&ons The list… 1.  Preopera&ve & anesthesia checklists to prevent opera&ve and postopera&ve events 2.  Preven&on bundles, including checklists to prevent opera&ve and postopera&ve events 3.  Interven&on to reduce urinary catheter use, including reminders, stop orders or nurse ini&ated removal protocols 4.  Preven&on bundles targe&ng ven&lator-‐associated pneumonia 5.  Hand hygiene 6.  Do not use list for “Hazardous” abbrevia&ons 7.  Mul&component interven&ons to reduce pressure ulcers 8.  Barrier precau&ons to prevent hospital-‐acquired infec&ons 9.  Use of ultrasound for central line placement 10.  Deep-‐vein thrombosis preven&on interven&on Role of professionals •  Become ac&ve leaders in encouraging and demanding improvements in pa&ent safety. •  SeMng standards, convening and communica&ng with members about safety •  Incorpora&ng a?en&on to pa&ent safety into training programs •  Collabora&ng across disciplines •  Contribute to crea&ng a culture of safety. –  As pa&ent advocates, health care professionals owe their pa&ents nothing less. Role of the pa&ent Five Steps to Safer Health Care •  1. Ask ques&ons if you have doubts or concerns. •  2. Keep and bring a list of ALL the medicines you take. •  3. Get the results of any test or procedure. •  4. Talk to your doctor about which hospital is best for your health needs.. •  5. Make sure you understand what will happen if you need surgery. AHRQ 98 Conclusions •  Human beings will always make errors •  Errors are common in medicine, killing tens of thousands •  Naming, blaming and shaming have no remedial value •  Safety cannot be a priority – it must be a precondi;on Care: 1. 
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It is safe It is eﬀec&ve It is eﬃcient It is pa&ent centered It is equitable It is &mely Pa&ent’s Perspec&ve: •  Don’t harm me •  Heal me •  Be nice to me Institute of
Medicine
2001
100
Simply put… Doing the right thing, the right way, at the right &me, in the right amount, for the right pa&ent that does not result in harm to the pa&ent 101
“It is not the strongest of the species that survives,
not the most intelligent,
but the one most responsive to change.”
Charles Darwin
Our Charge… “Crea1ng a world where pa1ents and those who care for them are free from harm” Na&onal Pa&ent Safety Founda&on (Jan 2014) References