Microsystem Patient Safety Scenario

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Figure 8.1 illustrates a hypothetical scenario that volume authors Julie K.Johnson and Paul Barach have used to connect patient safety principles with clinical microsystems thinking. In this scenario the patient is Allison, a five-year-old preschooler with a history of "wheezy colds." As we follow the scenario, it is clear that Allison and her mother interact with several microsystems as they navigate the health care system in an attempt to address Allison's illness—the hypothetical community-based pediatric clinic (which we call Mercy Acute Care Clinic) and several overlapping microsystems within the university hospital.

While working through this scenario, the reader will see many obvious points where the system failed, where it did not address Allison's needs. What are the ways to think about these system failures? Many valuable tools are available for

FIGURE 8.1. MICROSYSTEM PATIENT SAFETY SCENARIO.

Allison comes home from preschool with a cough and cold.

Allison comes home from preschool with a cough and cold.

Allison's mom, Leslie, takes her to Mercy Acute Care Clinic.

Dr. Curtis examines Allison and diagnoses her with asthma.

Allison, a 5-year-old preschooler, usually healthy but has a history of "wheezy colds."

The clinic is busy and to save time and not scare Mom, Dr. Curtis calls it "wheezy bronchitis" and prescribes an albuterol inhaler.

Leslie calls Dr. Curtis repeatedly; each time Nurse Hathaway assures her that Allison does not need to come in for another visit.

Leslie calls Dr. Curtis repeatedly; each time Nurse Hathaway assures her that Allison does not need to come in for another visit.

At this time of year, doctors' offices are always swamped with flu patients. Besides, Allison's mom has always been a little overprotective and quick to call us about any little problem.

Dr. Greene, admitting resident, writes orders for nebulizer treatments, IV prednisone, and ampicillin.

Leslie,

22 years old, unmarried, lives with her mother.

Dr. Curtis, board certified pediatrician, practicing in the community for 15 years.

The clinic is busy and to save time and not scare Mom, Dr. Curtis calls it "wheezy bronchitis" and prescribes an albuterol inhaler.

Back at home, Allison has a hard time using the inhaler. Her cough persists.

Back at home, Allison has a hard time using the inhaler. Her cough persists.

Several days later, Allison is still coughing and seems sicker. Leslie takes her back to Mercy Acute Care Clinic.

Allison is diagnosed with worsening asthma and pneumonia. Decision made to admit her to University Hospital.

Allison is diagnosed with worsening asthma and pneumonia. Decision made to admit her to University Hospital.

Sam Havenhurst, the hospital pharmacist receives the order and sends it to the floor.

Allison develops hives and worsened breathing after IV ampicillin and is intubated.

Leslie is so upset about admission that she forgets to say that Allison is allergic to penicillin.

The computer system is down (again) so Sam Havenhurst can't check the electronic record for patient allergies.

analyzing medical errors, such as morbidity and mortality conferences, root cause analysis, and failure mode and effects analysis. Although it is tempting to rely on one or two tools in an attempt to simplify the complexity involved in understanding errors and patient harm, the challenge for most health care professionals is to preface the search for root causes with a broader look that will help them place the error in context. One method that we have found to be useful for taking this broader look builds on William Haddon's overarching framework for injury epidemiology (Haddon, 1972).

As the first director of the National Highway Safety Bureau (1966 to 1969), Haddon was interested in the broad issues of injury that results from the transfer of energy in such a way that inanimate or animate objects are damaged. Haddon (1973) identified ten strategies for reducing losses:

1. Prevent the marshaling of the energy.

2. Reduce the amount of energy marshaled.

3. Prevent the release of the energy.

4. Modify the rate or spatial distribution of release of the energy.

5. Separate in time and space the energy being released and the susceptible structure.

6. Use a physical barrier to separate the energy and the susceptible structure.

7. Modify the contact surface or structure with which people can come in contact.

8. Strengthen the structure that might be damaged by the energy transfer.

9. When injury does occur, rapidly detect it and counter its continuation and extension.

10. When injury does occur, take all necessary reparative and rehabilitative steps.

These strategies have a logical sequence that can be described in terms of pre-injury, injury, and post-injury.

The Haddon framework is a 3 X 3 matrix in which the factors involved in an automobile injury (human, vehicle, and environment) head the columns, and the phases of the event (pre-injury, injury, and post-injury) head the rows. Figure 8.2 shows a completed Haddon matrix. It focuses the analysis on the relationships among the three factors and the three phases. A mix of countermeasures derived from Haddon's strategies is necessary to minimize loss. Furthermore countermeasures can be designed for each phase—pre-event, event, and post-event. This approach confirms what is known about adverse events in complex environments: it takes a variety of strategies to prevent or mitigate harm. Understanding injury in its larger context helps leaders and staff recognize the basic fragility of systems and the importance of mitigating inherent hazards by increasing the resilience of the system (Dekker, 2002).

FIGURE 8.2. HADDON MATRIX ANALYZING AN AUTO ACCIDENT.

Factors

Human

Vehicle

Environment

Pre-injury

Alcohol intoxication

Braking capacity of motor vehicles

Visibility of hazards

Injury

Resistance to energy insults

Sharp or pointed edges and surfaces

Flammable building materials

Post-injury

Hemorrhage

Rapidity of energy reduction

Emergency medical response

Source: Haddon, 1972.

Source: Haddon, 1972.

FIGURE 8.3. COMPLETED SAFETY MATRIX FOR ALLISON'S SCENARIO.

Provider

Factors Patient and Family

System and Environment

Pre-event

Physician decision about diagnosis

Child with history of wheezy colds

Busy primary care clinic University hospital

Event

IV ampicillin

Allergy to penicillin

Computer systems down

Post-event

Intubation

Hives, difficulty breathing

Hospital—team response to allergic reaction

Building on injury epidemiology, we can also use the Haddon matrix to think about analyzing medical injuries (Layde et al., 2002). To translate this tool from injury epidemiology to patient safety, we have revised the phase descriptions from pre-injury, injury, and post-injury to pre-event, event, and post-event. We have revised the factor descriptions from human, vehicle, and environment to provider, patient and family, and system and environment. In this latter factor, system refers to the processes and systems that are in place for the microsystem. Environment refers to the context within which the microsystem exists. We added system in order to recognize the significant contribution that systems make toward harm and error in a microsystem. Figure 8.3 shows a completed matrix derived from Allison's scenario and illustrating how the Haddon matrix may be adapted for analysis of medical injuries.

The next step in learning from errors and adverse events is to develop coun-termeasures to address the issues in each cell of the matrix. To examine this step and further describe safety issues in microsystems, we will move from the hypothetical scenario to the following case study.

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