innovative techniques for physicians to improve safety tammy lundstrom, md detroit medical...
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Innovative Techniques for Physicians to Improve Safety
Tammy Lundstrom, MDDetroit Medical Center-Wayne State University
VP, Chief Quality and Safety Officer
Improving Patient Safetymeans . . .
Reducing medical errors.
Reducing patient harm.
Patient Safety Terminology
Structure Process Outcome
Root causes Proximate cause Sentinel event
Blunt end Sharp end Patient
Hazards Failures Harm
Latent conditions Active failure Adverse event
Overview of a Comprehensive Program
Detroit Medical Center
13,000 employees 3000 physicians 1000 Graduate Medical Residents 1000 Medical Students Nursing Students Pharmacy Students PA Students
Demonstration of Leadership Support Name of System Quality Council changed
to System Quality-Medical Safety Council Chief Medical Safety Officer named Medical Safety Committee Established Monthly reports to the Board Medical Safety Plan Developed
Value of a Comprehensive Program Reduce fear of reporting errors/near
misses, gather more data Reduce errors through tracking,
trending,analysis, and targeted improvement projects
Reduce errors through prevention
Comprehensive Program
C om p reh en s ive M ed ica l S a fe ty P rog ram
E m p loyee S afe ty P atien t S a fe ty E n viron m en ta l S a fe ty
M ed ica l S a fe ty C om m itteeC h a ir- C h ie f M ed ica l S a fe ty O ffice r
First Steps
Common definitions agreed upon Common database to enter events Information flows through each site
Leadership and Performance Improvement Committee
Information flows from site to system Critical aspects of safety agreed upon
What is a Safety Culture
And how is it achieved?
Lessons from a Leader
“Safety is not a priority, it’s a way of life”
Paul O’Neill
CEO Alcoa Steel
Treasury Secretary
Safety Culture Involves Paradigm Shift
OLD
Who did it?
Focus on bad event
-Root Cause
Top down
Punish bad behavior
NEW
What happened?
Focus on Near Miss
-FMEA
Bottom up
Fix broken processes
Advantage to Focus on near Misses No patient harm, therefore no blame No guilt Focus on prevention No fear of litigation
Disclosure of Unanticipated Outcomes to Patients and Families
What is an Unanticipated Outcome?
A negative or unexpected result stemming from– A diagnostic test, medical judgment or
treatment, surgical intervention, or (commission)
– The failure to perform a necessary test, treatment , or intervention (omission)
Why Disclosure?
We are our patient’s advocates Literature shows that after an unanticipated
outcome, the patient and family want to know honestly what happened, and how the hospital is going to prevent future events
Rebuilds trust Caregiver/Doctor relationship
Advocating Disclosure
American Society for Healthcare Risk Managers
JCAHO AHA AMA
JCAHO
Standard
RI.1.2.2 Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.
AHADevelop an institutional policy or position
statement on disclosure of unanticipated outcomesDifferentiate between disclosure of an unanticipated
outcome and an admission of liabilityDetermine who will be responsible for informing
the patient, and, where appropriate, the family and/or legal representative, about the unanticipated outcome.
Educate caregivers and staff about your organization’s policies and procedures covering this issue, and consider communications training for those charged with disclosing unanticipated outcomes
Specify documentation requirements regarding disclosure
ASHRM
Each Healthcare institution must develop it’s own policy on management of unanticipated outcomes
Disclosure of such information to patients and families must reflect the requirements of applicable law
Differentiate between unanticipated outcome and admission of liability
For additional detail on implementation of a policy on disclosure of outcomes, consistent with the requirements of this standard:
AMA
AMA Professional Code of Ethics
Steps to Follow After Event
Care for immediate needs of patient Preserve evidence (Medical equipment) Document in the medical record Report (Risk Management) Disclose
Documentation
Document only the facts of what occurred and treatment rendered
NOT– Blame– Subjective feelings, opinions– Speculation– Reference to “Incident report”
Incident Report
Complete and submit Notify Risk Management FDA notification if Medical Device or
Medication Begin Root Cause/Intensive analysis to
examine process changes that may prevent future events
Who Will Inform the patient?
The attending physician May need pre-disclosure conference with
Nursing, Risk Management All patient questions should be referred to
the attending physician
When Should Disclosure Occur?
As soon as possible after immediate needs of patient addressed
Gather facts FIRST May not have all the facts yet, in which
case DON’T SPECULATE! Offer to speak again as facts become known
How?
Convey compassion– “I am sorry for your…..” “I am sorry that you…”
Known facts Privacy No BLAME on any member of healthcare team Avoid defensive posture/reaction Respond to patient complaints (provide forms,
contact patient advocates/ombudsman)
Health Care Worker Involved in Error AVOID BLAME Provide counseling, if needed
Remember: No one goes to work intending to make a mistake
HCW feel tremendous guilt after event that harms patient
Examples from the Front Lines
Physician Leadership is Key
Medication Safety
Why physicians?
Medication Safety
Large % medication errors due to prescribing (20-49%)
For the most part- physicians prescribe DMC Medication Safety Committee
– Physician Chair– Review all events– Review ISMP alerts/External incidents– Chemotherapy Administration Policy
Medication Safety- Physician Lead PI Look-alike Sound-alike Posters and alerts Define safe medication order writing
policy/pocket card Promote physician incident entry Develop delineation of privileges form
related to chemotherapy administration
Dangerous Abbreviation
Intended Meaning Misinterpretation Recommendation
U Units Mistaken as a zero or a four when poorly written, resulting in overdose. (4U seen as "40" or 4U seen as "44")
Use units
g Micrograms Mistaken for "mg" when handwritten, resulting in overdose
Use mcg
q.o.d. or Q.O.D.
Every other day Misinterpreted as qd or qid if the "o" is poorly written.
Use every other day or q 48 hours and time/day to begin therapy
TIW Three times a week Misinterpreted as "three times a day" or "twice a week"
Use three times a week
cc Cubic centimeters Misread as "u" (units) Use mL
AUASAD
Both earsLeft earRight ear
Misinterpreted as "OU", "OS", and "OD". Use both ears, left ear or right ear
OUOSOD
Both eyesLeft eyeRight eye
Misinterpreted as "AU", "AS', and "AD" Use both eyes, left eye or right eye
Physician Education
Physician Led
Board Support All physicians and trainees will have 3 hours of
mandated compliance and safety education each credentialing cycle
Failure to complete required education will be deemed voluntary resignation
Web-based Continuing Medical Education credits Required for all new applications to the Medical
Staff Physician experts develop and approve education
modules
Physician Education Modules
Sexual Harassment Code of Conduct Pain Management Medical Safety and Incident Reporting Restraint Use Conscious Sedation Infection Control Life Safety
Moderate Sedation
for Physicians and
Licensed Independent Practitioners
Moderate Sedation
Moderate sedation/analgesia describes a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Moderate Sedation Patient Evaluation Standards History and Physical includes:
– abnormalities of major organ systems with specific focus on the cardiopulmonary history
– pregnancy status
– previous adverse experiences with sedation/analgesia, as well as anesthetic techniques
– current medications and drug allergies/adverse reactions
– time and nature of last oral intake of foods, fluids, etc.
– history of tobacco, alcohol, or substance use or abuse
Moderate Sedation Patient Evaluation Standards Focused physical exam that minimally includes an
evaluation of the airway and auscultation of the heart and lungs.
Assignment of ASA Classification of Physical Status Pre-procedure laboratory and diagnositic testing guided by
the patient’s underlying medical condition. History and physical examination are valid up to 30 days
prior to the scheduled procedure. Verification and review of this information is necessary immediately prior to the provision of moderate sedation.
Moderate Sedation Monitoring Standards
Level of consciousness– Monitoring the patient’s response to verbal and/or tactile stimuli
should be routine (unless contraindicated by procedure). Pulmonary Ventilation
– Ventilatory function is continually monitored by observation and/or auscultation during the procedure.
Oxygenation– Continuously monitored by pulse oximetry with appropriate low
limit alarms. Hemodynamics
– Baseline blood pressure established; measured at regular intervals intra and post-procedure. Electrocardiograph continuously monitored.
Moderate SedationEmergency Equipment Pharmacologic Antagonists and resuscitation
drugs Intravenous access Supplemental oxygen Advanced airway equipment Cardiac defibrillator
Moderate SedationDischarge Criteria Following the provision of moderate sedation, patients are
monitored until they are suitable for discharge:– Level of consciousness and hemodynamic/respiratory variables
evaluated and no longer at risk for sedation and cardiorespiratory depression.
– For patients who received pharmacologic antagonists, post-procedure monitoring should continue for a sufficient period of time to detect and appropriately treat its recurrence.
Discharge criteria that pertain to the patient population and specific procedures is developed:– A qualified physician or registered nurse should be in attendance
until discharge criteria are fulfilled.
Sharps Safety
Why Physicians?
Physician-Performed TestingRequirements Dfn: Test personally performed by a
physician in conjunction with the physical examination or treatment of a patient
PPT
Amniotic fluid pH Cervical mucous smears for ferning Fecal leukocytes Gastric biopsy urease Nasal smears for eosinophilia Occult blood, fecal and gastric Pinworm exam
PPT
Post-coital mucous exam Potassium hydroxide preparations Semen analysis, qualitative Synovial fluid for crystals Urine dipstick Urine sediment microscopy Vaginal wet mount microscopy
What’s required?
Policy- scope of testing for physicians Procedure manual- specimen handling QI program
– Quality control, reagents
– Instrument maintenance
– Corrective action equipment/reagent failure
Documented training- test specific Competency assessment-credentialing System for reporting results
How will you comply?
Training and documentation Reagent control
– No bottles in pockets!!
House staff? Other trainees?
Sharps Safety
Physicians perform many procedures– Forgotten “frontline worker”
Physician sharps injuries under-reported HIV conversions
– 57 documented conversions
– 6 physicians
Many Safety devices used primarily by physicians– Safety Scalpels
– Blunted suture needles
Physician Peer review and Patient Safety
Incident Reports
Incident Occurs
Root Cause
-Process
Peer Review
-Physician specific practice as it relates to care of this patient
Goal of Peer Review
Monitor and improve physician care of patients
Accomplish by:– Open, non-punitive discussion – Review and discuss alternatives– Disseminate to ALL physicians
Monthly Vignettes
Code Blue
Get away from “monitoring Code” Move towards: review previous 48 hour
record– Could this event have been prevented?– Were signs of deterioration missed?
• Elevated BP, dropping BP
• Elevated HR, dropping HR
• Elevated RR