When we speak of “quality” in health care, we generally think of mortality outcomes or regulatory requirements that are mandated by the JCAHO (Joint Commission for Accreditation of Healthcare Organizations). But how do these relate to and impact our everyday lives as hospitalists? At the 8th Annual Meeting of SHM we presented a workshop on RCA and FMEA, taking a practical approach to illustrate how these two JCAHO required methodologies can improve patient care as well as improve the work environment for hospitalists by addressing the systemic issues that can compromise care.
The workshop starts by stepping into the life of a hospitalist and something we all fear: “Something bad happens. Then what?” Depending on the severity of the event, the options include peer review, notifying the Department Chief, calling the Risk Manager, calling your lawyer, or doing nothing. You’ve probably had many experiences when “something wasn’t quite right,” but often there is no obvious bad outcome or obvious solution, so we shrug our shoulders and say, “Oh well, we got lucky this time; no harm, no foul.” The problem is, there are recurring patterns to these types of events, and the same issues may affect the next patient, who may not be so lucky.
Defining “Something Bad”
These types of cases, which have outcomes ranging from no effect on the patient to death, may be approached several different ways. The terms “near miss” or “close call” refer to an incident where a mistake was made but caught in time, so no harm was done to the patient. An example of this is when a physician makes a mistake on a medication order, but it is caught and corrected by a pharmacist or nurse.
When adverse outcomes do occur, think about and define etiologies so that you identify and address underlying causes. Is the outcome an expected or unexpected complication of therapy? Was there an error involved? In asking these questions, remember that you can have harm without error and error without harm. Error is defined as “failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim; the accumulation of errors results in accidents” (Kohn, et al). This definition points out that usually a chain of events rather than a single individual or event results in a bad outcome. The purpose of defining etiologies is not to assign blame but to identify underlying issues and surrounding circumstances that may have contributed to the adverse outcome.
Significant adverse events are called “sentinel events” and defined as an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function” (JCAHO 1998).
How We Approach Error
Unfortunately, as humans we are fallible and make errors quite reliably. Table 1 demonstrates types of errors and expected rates of errors. For example, we make errors of omission 0.01% of the time, but the good news is that with reminders or ticklers, we can reduce this rate to 0.003%. Unfortunately, when humans are under high stress in danger, research from the military indicates error rates of 25% (Salvendy 1997). In a complex ICU setting, researchers have documented an average of 178 activities per patient per day with an error rate of 0.95%. Despite an error rate of less than 1%, the yield of errors during the 4-month period of observation was still over 1000 errors, 29% of which were considered to have severe or potentially severe consequences (Donchin, et al).
click for large versionAdapted from: park K. Human error. In: Salvendy G, ed. Handbook of human factors and ergonomics. New York: John Wiley & Sons; 1997.
Table 1.