Master Ramponi 25.10.08

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Errori in Medicina: cosa fare?

Master in Malattie RareTorino 25 Ottobre 2008Carlo Ramponi, JCI

Client name/ Presentation Name/ 12pt - 2

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• una organizzazione indipendente, non-governativa, not-for-profit

• leader internazionale riconosciuta nel campo dei progetti di miglioramento della qualità in ambito sanitario

• pioniere nello sviluppo delle misure di performance e di outcome per le organizzazioni sanitarie

Cosa é Joint Commission


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Joint Commission Internationalwww.jointcommissioninternational.org

JCI é una divisione not-for-profit di TJC; la sua mission é quella di migliorare la

qualità dell’assistenza sanitaria in ambito internazionale, fornendo servizi

connessi con il processo di accreditamento.


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Il significato di accreditamento JCI

un processo volontario attraverso il quale un ente terzo, non governativo, riconosce e afferma che un’organizzazione sanitaria rispetta specifici standard che richiedono un continuo miglioramento nelle strutture

nei processi e nei risultati


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JCI’s 200 accredited organizations are spread over 24 co untries


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Quanto spesso succede?– E’ il piu’ comune Evento Sentinella segnalato

a TJC in USA– Dal 1995 sono stati sottoposti a RCA 651 casi

(13%)– Lo Stato del Minnesota richiede SE reporting

ai propri ospedali e pubblica i risultati– Nel 2007: 35 wrong site surgical procedures– Minnesota conta 1.7% della popolazione USA

– Estrapolando questi numeri….� 6 wrong site surgical procedures negli

USA ogni giorno---365 giorni all’anno.


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A proposito di gestione farmaciinvece..

– Ci sono sei sottosistemi che compongono ilsistema detto “medication management” :

– 1) selecting and procuring,

– 2) storage of medications, – 3) ordering (prescribing), – 4) preparing and dispensing,

– 5) administering, and – 6) monitoring the patient’s response.


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A proposito di farmaci invece..

– L’incidenza di errori nella gestione deifarmaci e’ stata stimata –nel caso dipazienti adulti ricoverati- pari al 5% ditutti gli ordini scritti

– nel caso dei ricoveri pediatrici, l’incidenza e’ stata stimata pari a 1 ogni6.4 prescrizioni


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– In uno studio che ha interessato 1116 ospedali, il 5.07% dei pazienti ricoveratiha sperimentato un errore di terapiafarmacologica. Questo valore e’ consistente con tassi di errore dal 3 al 6.9% riportati in altri studi.


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IOM Report brief July 2006


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Quali proposte?

– Agire sulla cultura del rischio, adottareprotocolli e procedure evidence-based, insistere, insistere, insistere

– Oppure

– Agire sul portafoglio: la nuova frontiera!


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Agire sulla cultura del rischio: un esempio

WHO Patient Safety Solutionshttp://www.ccforpatientsafety.org/30723/

1. Look-Alike, Sound-Alike Medication Names 2. Patient Identification 3. Communication During Patient Hand-Overs4. Performance of Correct Procedure at Correct Body Si te5. Control of Concentrated Electrolyte Solutions 6. Assuring Medication Accuracy at Transitions in Care 7. Avoiding Catheter and Tubing Mis-Connections 8. Single Use of Injection Devices 9. Improved Hand Hygiene to Prevent Health Care-Associ ated Infection (HAI)


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Agire sulla cultura del rischio: un altro esempio

– Guidelines for Implementing the Universal Protocol for Preventing Wrong Site, Wrong

Procedure and Wrong Person Surgery™http://www.jointcommission.org/PatientSafety/

UniversalProtocol/


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Definition

A Patient Safety Solution is any system design or intervention that has demonstrated the ability to prevent or mitigate patient harm stemming from the processes of health care.


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Solutions Template

• Solutions Title• Statement of Problem• Background, Issues & Potential Benefits• Solution• Applicability• Patient Involvement• Strength of Evidence• Risk Assessment/Barriers• References/Resources


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Confusing drug namesConfusing drug names is one of the most common causes of is one of the most common causes of medication errors and is a worldwide concern. With tens of medication errors and is a worldwide concern. With tens of

thousands of drugs currently on the market, the potential for erthousands of drugs currently on the market, the potential for error ror created by confusing brand or generic drug names and created by confusing brand or generic drug names and

packagingpackaging is significant. The recommendations focus on using is significant. The recommendations focus on using protocols to reduce risks and ensuring prescription legibility oprotocols to reduce risks and ensuring prescription legibility or the r the

use of preprinted orders or electronic prescribing.use of preprinted orders or electronic prescribing.


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rcesThe widespread and continuing failures to correctly identify patThe widespread and continuing failures to correctly identify patients ients

often leads to medication, transfusion and testing errors; wrongoften leads to medication, transfusion and testing errors; wrong person person procedures; and the discharge of infants to the wrong families. procedures; and the discharge of infants to the wrong families. The The recommendations place emphasis on methods for verifying patient recommendations place emphasis on methods for verifying patient

identity, including patient involvement in this process; standaridentity, including patient involvement in this process; standardization of dization of identification methods across hospitals in a health care system;identification methods across hospitals in a health care system; and and

patient participation in this confirmation; and use of protocolspatient participation in this confirmation; and use of protocols for for distinguishing the identity of patients with the same name.distinguishing the identity of patients with the same name.


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rcesGaps in handGaps in hand--over (or handover (or hand--off) communication between patient care off) communication between patient care

units, and between and among care teams, can cause serious units, and between and among care teams, can cause serious breakdowns in the continuity of care, inappropriate treatment, abreakdowns in the continuity of care, inappropriate treatment, and nd potential harm for the patient. The recommendations for improvipotential harm for the patient. The recommendations for improving ng

patient handpatient hand--overs include using protocols for communicating critical overs include using protocols for communicating critical information; providing opportunities for practitioners to ask aninformation; providing opportunities for practitioners to ask and resolve d resolve

questions during the handquestions during the hand--over; and involving patients and families in the over; and involving patients and families in the handhand--over process. over process.


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Considered totally preventable, cases of wrong procedure or wrong site surgery are largely the result of miscommunication and unavailable, or

incorrect, information. A major contributing factor to these types of errors is the lack of a standardized preoperative process. The

recommendations to prevent these types of errors rely on the conduct of a preoperative verification process; marking of the operative site by the practitioner who will do the procedure; and having the team involved in

the procedure take a “time out” immediately before starting the procedure to confirm patient identity, procedure, and operative site.


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While all drugs, biologics, vaccines and contrast media have a While all drugs, biologics, vaccines and contrast media have a defined risk profile, concentrated electrolyte solutions that ardefined risk profile, concentrated electrolyte solutions that are used e used

for injection are especially dangerous. The recommendations for injection are especially dangerous. The recommendations address standardization of the dosing, units of measure and address standardization of the dosing, units of measure and

terminology; and prevention of mixterminology; and prevention of mix--ups of specific concentrated ups of specific concentrated electrolyte solutions. electrolyte solutions.


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Medication errors occur most commonly at transitions. MedicatioMedication errors occur most commonly at transitions. Medication n reconciliation is a process designed to prevent medication errorreconciliation is a process designed to prevent medication errors at patient s at patient

transition points.transition points. The recommendations address creation of the most The recommendations address creation of the most complete and accurate list of all medications the patient is curcomplete and accurate list of all medications the patient is currently takingrently taking——

also called the “home” medication list; comparison of the list aalso called the “home” medication list; comparison of the list against the gainst the admission, transfer and/or discharge orders when writing medicatadmission, transfer and/or discharge orders when writing medication orders; ion orders;

and communication of the list to the next provider of care wheneand communication of the list to the next provider of care whenever the ver the patient is transferred or discharged.patient is transferred or discharged.


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rcesThe design of tubing, catheters, and syringes currently in use iThe design of tubing, catheters, and syringes currently in use is s

such that it is possible to inadvertently cause patient harm thrsuch that it is possible to inadvertently cause patient harm through ough connecting the wrong syringes and tubing and then delivering connecting the wrong syringes and tubing and then delivering medication or fluids through an unintended wrong route.medication or fluids through an unintended wrong route. The The

recommendations address the need for meticulous attention to recommendations address the need for meticulous attention to detail when administering medications and feedings (i.e., the ridetail when administering medications and feedings (i.e., the right ght route of administration), and when connecting devices to patientroute of administration), and when connecting devices to patients s

(i.e., using the right connection/tubing).(i.e., using the right connection/tubing).


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rcesOne of the biggest global concerns is the spread of Human

Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and the Hepatitis C Virus (HCV) because of the reuse of injection

needles. The recommendations address the need for prohibitions on the reuse of needles at health care facilities; periodic training of

practitioners and other health care workers regarding infection control principles; education of patients and families regarding transmission of

blood borne pathogens; and safe needle disposal practices.


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2008 Solutions1. Preventing Pressure Ulcers2. Responding to the Deteriorating

Patient3. Communicating Critical Test Results4. Preventing Central Line Infections5. Preventing Patient Falls in Health

Care Organizations


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Criteri da considerare

– Ci sia evidenza che l’insieme degli EA in questionepuo’ essere prevenuta con un’ampia adozione dipratiche disponibili e fattibili

– Gli EA possono essere accuratamente misurati in un modo verificabile

– Gli EA danno origine a danni clinicamente significativiper il paziente

– E’ possibile, attraverso la revisione della cartellaclinica, differenziare gli EA iniziati in ospedale daquelli gia’ presenti al momento dell’ammissione


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For more information:

The Joint Commission Resources Web Sitewww.jcrinc.com

The Joint Commission Internationalwww.jointcommissioninternational.org

Joint Commission International Center for Patient S afetywww.jcipatientsafety.org

[email protected]

Master Ramponi 25.10.08

Health & Medicine

Transcript of Master Ramponi 25.10.08