Healthcare worker and patient safety(jaeholee)
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2013년 6월 5일 의료종사자 보건안전포럼 발표자료
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Healthcare worker and patient safety(jaeholee)
- 2. 목차 • 의료와 환자안전 • 환자안전에 대한 인식 • 환자안전과 인적 요인 • 의료종사자의 안전
- 3. Iatrogenesis - clinical, social, cultural Medicalization Homo Medicus “병원이 병을 만든다” “Modern medicine makes more people sick than it heals” - Ivan Illich - Medical Nemesis?
- 4. 위해사건: 2.9-3.7%/입원환자 사망자: 44,000-98,000명/년 투약오류 사망: 7,000명/년 Institute of Medicine, 1999 Medical Nemesis?
- 5. Medical Nemesis? 영국(2009-2012): “Never Events” http://www.bbc.co.uk/news/health-22366147
- 6. Source: Lucian Leape, 2/2001 How hazardous is healthcare?
- 7. • 1.7 mistakes / patient / day in ICU • 1% failure rate is too high • Even 99.9% may not be good enough Leape LL. Error in Medicine. JAMA 1994; 272(23): 1851-7. How hazardous is healthcare?
- 8. 10년전 일본의 환자안전사건 • 암 연구회부속병원(도쿄) 상용량보다 3배 많은 용량의 항암제투여로 환자사망 • 국립 츠쿠바대학 부속병원(이바라키현) 감염 환자와 폐암 환자를 착각하여 폐 절제수술 • 니이카타 현립암센터 니이가타병원 (니이가타현) 유방암 수술에서 실수로 이상없는 유방절제 발각 • 다카오카 시민병원 (도야마현) 컴퓨터조작 실수로 근육이완제 투여, 폐렴환자 사망
- 10. 왜 매년 똑같은 사고가 반복되는가? ‘또’ 전공의 실수, 빈크리스틴 사망 사건 발생유가족· 환자단체, 인천 모 대학병원 “살인행위” 맹비난 2012.10.23 11:54 입력 http://www.dailymedi.com/news/view.html?section=1&category=4&no=759805&opage=2
- 11. • Invasive Practice • Dealing with Hazards • Dealing with Human life • Highly Qualified Resources Error free vs. Error tolerant The Nature of Healthcare
- 12. • Variable input • Complexity • Lack of standardization • Tightly-coupling • Heavily dependent on human intervention • Time constraints: tight & loose • Culture: hierarchical vs. team-oriented The Nature of Healthcare: High-risk Processes
- 13. • Unbounded demand • Multiplicity of patients & inherent variability • Uncertainty of diagnosis • Narrow time windows • Decision density & cognitive load • Poor feedback • Interruptions & distractions • Fatigue & shift work * P Croskerry, KS Cosby, S Schenkel, R Wears. Patient Safety in Emergency Medicine. 2008:p19 The Nature of Emergency Medicine
- 14. • Lacks of Awareness: Unreported “Isolated, Unusual” events • Most errors do no harm • “Culture of Silence” Error as a failure of character • Medical Malpractice Threat Even a minor error High Incident Rates of Error
- 15. 환자안전에 대한 인식
- 16. Danish Medical Association Survey (2002-2003)* • 의사의 1/3 정도가 위해사건에 대한 두려움으로 직업변경을 고려한다. • 위해사건으로부터 배우는 것이 없다. • 기밀성이 유지된다면 위해사건을 보고 할 것이다. * J. Poulsen, “The Danish Patient Safety Act” (2005) Denmark
- 17. 의료오류를 경험한 의사: 미국 • 내과 레지던트 (N=184) • 심각한 의료오류를 저지른 적이 있는가? > 1회/1년 : 34% • 의료오류 비경험군과 경험군 정신건강 Depersonalization (MBI-DP) : 6.62 vs. 9.85 Emotional exhaustion (MBI-EE): 19.21 vs. 26.06 Depression(%): 33.02 vs. 63.33 • 병적대처/ 자신감 상실/ “쓸모없는 존재” (JAMA, 2005)
- 18. 김정은 등. 환자안전 문화와 의료과오 보고에 대한 의사의 인식과 태도. 보건행정학회지 2005;15(4):110- 135. 의료오류에 대한 인식: 국내 의사
- 19. • 소속 병원에 심각한 안전문제가 있다: 52.4% • 더 심각한 실수가 발생하지 않은 것은 단지 우연일 뿐: 82.5% • 소속 병원의 시스템이 의료실수를 예방하는데 적합하다: 33.1% • 환자에게 해가 되는 의료실수를 ‘항상’ 보고하지 않는다: 66.5% • 어떤 종류의 의료실수들이 보고돼야 하는지 명확하지 않다: 50.6% • 의사와 간호사가 한 팀으로 협력하는데 문제가 있다: 69.9% • 문제가 발생했을 때도 의사와 이야기하는 것이 어렵다: 56.3% Kim J et al. Nurses' Perception of Error Reporting and Patient Safety Culture in Korea. Western Journal of Nursing Research 2007;29(7):827-844 . 국내 간호사 인식, 2007년 서울시내 8개 대학병원 간호사 886명
- 20. 2nd Victims • Kimberly Hiatt’s case http://jhealthmedia.com/site/article/2012032625560.html • Serious medical errors 34%: 1/yr (residents), 3배 이상의 자살충동 (surgeons)
- 21. 2nd Victim Meaning, Joy, and Safety
- 23. Route Causes?
- 24. 환자안전과 인적요인
- 26. Cognitive Dispositions to Respond That May Lead to Diagnostic Error* Aggregate bias Gender bias Psych-Out Errors Anchoring Hindsight bias Representativeness Ascertainment bias Multip.Alternatives Search satisfying Availability Omission bias Sutton’s Slip Base rate neglect Order effects Triage-Cueing Commission bias Outcome bias Unpacking principle Confirmation bias Overconfidence Vertical line failure Diagnostic creep Playing the odds Visceral bias Attribution error Posterior prob. Ying-Yang Out Gambler’s Fallacy Premature closure Zebra retreat The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them. Acad. Med. 2003;78:775–780
- 27. Dawson – Nature, 1997 24 hrs of sleep deprivation’s performance effects: blood alcohol content 0.1%
- 28. Individual factors that predispose to error • Limited memory capacity • Further reduced by: – fatigue – stress – hunger – illness – language or cultural factors – hazardous attitudes
- 29. 의료종사자의 안전
- 32. • Graduate Medical Education (ACGME) is charged with setting and enforcing standards for supervision and resident duty hours for graduate medical education. This web site shares background and detail regarding proposed new standards developed by a special task force convened to review, deliberate and draft new standards that went into effect July 2011. ACGME Duty Hours
- 33. Registered Nurse Safe Staffing Act
- 35. 의료종사자와 환자의 안전 • The Nature of Healthcare & Patient Safety • Route Causes of Medical Error: Healthcare System • Patient Safety & Human Factors • Healthcare Workers Safety: meaning, joy, safety • Regulation for Safety: duty hours, staff numbers & level • Budget for Patient & Healthcare Worker Safety?