In health care too often we make the assumption that the human brain always functions accurately. When we make a mistake it is because we weren't paying attention. Using this logic, whenever an error harms a patient, it must have been caused by someone who was not concentrating and that person was simply not trying hard enough. And therefore he or she is to blame. If we think about our own lives we realize that we inadvertently make errors every day. We make a right turn instead of a left turn. We may misplace our keys or our wallet. We may forget an appointment. The more things we have to do, the more fatigued we are, the more likely these mistakes of commission doing the wrong thing. Or omission, forgetting to perform a task will occur. Overwork leads to fatigue and fatigue is known to increase the likelihood of mental errors. And health systems that overwork their caregivers are dangerous. Lack of sleep is well known to increase the likelihood of a mistake. In fact, staying up for 24 hours has been known to be the equivalent of having a blood alcohol level of 0.1 percent. That's about the legal limit of 0.08 percent for driving a car. When caregivers fail to get sufficient sleep they are endangering their patients. As a patient, if you see your doctor yawning and looking sleepy, beware. You should consider postponing any procedure until he or she is more rested, because you know that when your caregiver is sleepy, they probability of an error goes up. Emotional stress can also result in the loss of mental focus, and that is why disruptive caregivers are so dangerous. They distract others from focusing on the care of their patients. If your caregiver appears anxious, beware. Remember Josie King's mother noticed that the nurse who gave her daughter a fatal dose of methadone was unduly anxious. Whenever possible you should request caregivers who are calm and emotionally stable. In the era of handheld smartphones and computerized tablets, multitasking is the rule. However, when it comes to healthcare, we know that multitasking increases the likelihood of an error. Auto accidents associated with texting are a case in point. We all need to prioritize our tasks and perform one task at a time. If your caregiver is multitasking, beware, errors are likely to follow. Finally distractions and interrupts, interruptions increase the risk of mental errors. Excessive noise, alarm and pagers can reduce the mental concentration. Personally, when I am doing something important, my mind shuts out all of the extraneous stimuli. This reduces the likelihood I will make an error. However, this behavior really upsets my wife, because when I am concentrating, I often am not even aware she is asking me a question. But if you are a patient, don't you want your caregiver to devote 100% attention to your care? How do we prevent these mental errors? Simulation can help by ingraining good habits. When caregivers have practiced over and over again, efficient and effective behaviors become automatic and no longer require deep concentration. But even after practice, errors can occur for all the reasons I have just described. 80% of the time, errors are the consequences of poor systems that increase the likelihood of mental errors. Rather than being caused by caregivers who are lackadaisical and don't care. In other words, the majority of errors are the consequences of bad systems, not bad people. And in the majority of cases, we should avoid blame and shame. A supportive and understanding approach allows everyone to learn from errors so they can be prevented in the future. When the work processes are becoming too rushed and fatigue sets in, caregivers need to call a timeout and take a deep breath. They need to continually ask what is going well and what can be improved? Learning from our errors will allow us to progressively design systems of care that guard against mental errors. Let's look at a real case. Again, the name and age of the patient have been changed to maintain confidentiality. Mr. J, a 60 year old mechanic, is admitted to the Intensive Care Unit with severe pneumonia. The intravenous antibiotic Cefepime is begun. However, despite this treatment, his blood pressure begins to fall. The ICU physician orders treatment with intravenous Norepinephrine. An agent that constricts blood vessels and increases blood pressure. The busy ICU nurse receives a solution bag containing norepinephrine as well as a second bag that containing the next dose of his antibiotic, cefepime. While carrying the medication bags to his bedside, the nurse is paged. She sets down both bags at the bedside table and answers a page. Upon returning, she inadvertently places the norepinephrine bag on the I.V. pole intended for the antibiotic infusion and places the antibiotic bag on the pole intended for the norepinephrine infusion. As a consequence of this switch, norepinephrine is infused at the much faster rate designated for the antibiotic. The patients blood pressure rises acutely and his heart begins beating irregularly leading to a cardiac arrest and his death. The error is only discovered after Mr. J has died. Why did the nurse mix up the two medications? To fully explore the causes of fatal errors investigators perform what is called a root cause analysis or RCA. This approach is used for all sentinel events. A sentinel event as defined by the Joint Commission is "an unexpected occurrence involving death or serious physical or psychological injury, or has the potential to do so". Such events are called sentinel because they signal the need for immediate investigation and response. These investigations need to take place within 30 days because otherwise memories fail and the details of the event are permanently loss. RCAs are conducted by a multidisciplinary team and should include a family member of the injured patient whenever possible. The team identifies all contributing factors and collects al the necessary data. They create a quick fix and this is followed by plan, do, study, act cycles, the topic of our next session. The RCA should first identify what happened. Second, determine, review what should have happened. Third, determine the causes. Fourth, develop causal statements. And fifth, generate a list of actions to prevent a recurrence of the event. And finally, create a summary to share with leadership, staff and family members. One helpful tool for organizing the various contributing factors is called a fishbone diagram. The event is shown at the far right, at the end of the spine. The individual ribs are broken down into five categories. People, methods, environment, materials, and equipment. People, the nurse was stressed and fatigued and distracted. Methods, the nurse was multitasking, managing two sick patients. It did not have a nurse's aide, nor the assistance from the pharmacist. Environment. It was noisy with frequent disruptive pages. Materials. The medication IV bags looked alike. Labeling was small and not color coded. Equipment. No bar code reader or bar codes were available on the medications. IB lines were not color coded. A very useful tool for digging deeper into a cause of an error, is called a driver diagram. First we identify the most apparent causes of the error called primary drivers. By continually asking why, we can then identify additional factors called secondary drivers. Driver diagrams encourage the creation of a more comprehensive and effective improvement plan. Here is a driver diagram for our case. The primary drivers leading to the nurse mixing up the medications included fatigue, multi tasking, interruptions, and poor labeling of the medications. For each primary driver we can ask why? Why was the nurse fatigued? She had multiple family stresses and didn't sleep well. Why was she multi-tasking? She was covering two very sick patients and did not have the assistance of the nurse's aide. Why was she interrupted? Her pager went off, the orders for the patient were frequently being changed. Why was the laboring poor? We'll discuss these answers a little bit later. Based on our driver diagram, we now have a deeper understanding of what went wrong. And here is a summary of those conclusions. One of the points, because she had two sick patients, the nurse batched the administration of her IV medications. And we know that batching increases the likelihood of mixup. Now, lets dig into the final primary driver by asking why five times? Why did the nurse switch the two intravenous medications? Answer? Because the two bags looked alike and the labels had small black print. Why did the two medication bags look alike? Because an automatic printer prints out all the labels. Why? Because this approach saves time and is simple. Why? Because because simplicity and efficiency are emphasized by the director of the pharmacy. Why? Because the pharmacy director prides himself in eliminating all wasteful steps in medication management. The question now arises if this was the ICU nurses fault. Did her patient die of a medication error? Or was it the pharmacy's director's fault? Or could it be the person responsible for printing all the labels. Or the pharmacist who put the labels on the bag? Many people were involved and each of them could have prevented this mixup. As the famous Swiss cheese analogy for medical errors points out. In this case, all of the potential checks and balances failed. And the holes of the Swiss cheese aligned, allowing the mix-up to kill Mr. J. By applying root cause analysis, we can shrink these holes and prevent a future fatal mix-up of medications from harming another patient. And in the next section, we learn about the tool to shrink those holes called a plan do study act cycle. Thank you.