patient safety begins in the georgia society for ...teresa mcmillan, rn, msa, cphrn, lhrm, cpps...

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Patient Safety begins in the

Parking Lot

Georgia Society for Healthcare Risk Management

Teresa McMillan, RN, MSA, CPHRN, LHRM, CPPS Senior Risk and Patient Safety Consultant

Closed Claims Disclaimer

The case reports presented are a composite drawn from MagMutual’s case files. Names, pictures, and

small details have been changed. Any similarity to a specific case is both coincidental and unintended. The

risk management advice in the claims presented are intended as general information of interest to

physicians and other healthcare professionals. The recommendations and advice in this presentation do

not reflect a legal opinion, establish a standard of care, and do not establish rules for the practice of

medicine. Successful outcomes are not guaranteed. The publication of this information is not intended as

an offer to insure such conditions or exposures, or to indicate that MagMutual Insurance Company will

underwrite risks for the reader. Our liability is limited to the specific written terms and conditions of the

actual insurance policies issued.

©2015 MagMutual Insurance Company. All rights reserved.

Educational Objectives

At the conclusion of this presentation, the participant will be able to:

• Identify high-risk transitions of care

• Discuss the effect of communication on quality of care

• Discuss ways to promote high-quality transitional care among various

settings


The Parking Lot


The Case of Sawyer Hall


The Case of Sawyer Hall


6 providers involved

Urgent care, hospital and PCP

Numerous varying diagnoses

Ultimately diagnosed with Addison’s disease

Brain injury related to seizures, low sodium and low blood sugar

Continuum of Care

• Involving a system that guides and tracks patients over time

• Through a comprehensive array of health services

• Spanning all levels and intensity of care

• From birth to end of life

Continuum of Care


HIMSS HIE Committee Continuity of Care Workgroup. 2014

The Case of Will Justice


The Case of Will Justice

• X-ray report sent to PCP and ED physician

• Will Justice was diagnosed with lung cancer two years later


Care Transitions

Patient and

Family

PCP

ED

Inpatient

ICU

Inpatient

Home


Care Transitions

Patient and

Family

PCP

ED

Inpatient

ICU

Inpatient

Home


Home Health

School Nurse

Social Support

Specialty Clinic

Another Hospital

How do patients and families feel?


Why

How do medical providers feel?


Care Transitions

Patient-related

Provider-related


Movement of the patient between health care

practitioners, settings, and home as condition and

care needs change.

Provider-Related Transitions

• Hospitalist signs out to on-coming

hospitalist

• Physician signs out to partner

• Nursing staff changes from day to day or

shift to shift


Patient-Related Transitions

• Patient between care givers

• Patient referred to a specialist

• ED-Urgent Care-PCP

• Many others


Transition of Care Errors

Potential for catastrophic impact on patients

Diminished health and increased costs

Gaps in coordination and communication

Occur when responsibilities are transferred from one team to another

There and Home Again, Safely: 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association. 2013.


Transition of Care Errors

ECRI Study of 223 Events from 38 Facilities

Care Coordination: Executive Summary. ECRI Institute PSO Deep Dive. September 2015.

Adverse Events • 62% care coordination issues during

admission • 38% occurred during or after the discharge

process • 51% involved medications

Top Contributing Factors • Human factors • Policies and procedures • Staff limitations • Communication breakdowns


Communication

Key factor associated with medical errors

Root cause in 46.9% of sentinel events reported to

the Joint Commission

Verbal, recorded ,or written

Systems and processes • Medication reconciliation • Time out

The Joint Commission: Office of Quality and Patient Safety. Sentinel Event Data: Root Causes by Event Type: 2004 - 3Q 2015. Chicago, IL: The Joint Commission, 2016. Transitions of Care: The need for a more effective approach to continuing patient care. Hot Topics in Health Care. The Joint Commission. www.thejointcommission.org.


The Case of Robin Black


The Case of Robin Black

• Allergist considered allergy to Solu-Medrol but did not document.

• Nurse did not document the potential allergy, failed to report at shift change, did not communicate with pharmacy, or pull med from automated dispensing system.

Communication-Risk Factors

Culture

Ineffective communication method

Time issues

Inaccurate or incomplete information

Duty prioritization

Improving Transitions of Care: Hand-Off Communications Story Board. Joint Commission Center for Transforming Healthcare. December 22, 2014. www.centerfortransforming healthcare.org

Communication-Impacting Outcomes

Delay in treatment Inappropriate treatment Adverse events Omission of care

Increased length of stay Increased costs Inefficiency from

rework

Negative patient outcome or

patient experience

Improving Transitions of Care: Hand-Off Communications Story Board. Joint Commission Center for Transforming Healthcare. December 22, 2014. www.centerfortransforming healthcare.org

The Patient’s Role

• Provide appropriate history • Provide health preferences,

needs, values • Involved in clinical decision

making • Center of care • Collaboration (medications,

diagnostic tests, treatments)

From the Patients Viewpoint

Authoritarian physicians

Fear of being labeled

Feeling of powerless

Health care literacy level

Uncertainty about basics of the health system

Dealing with inexperienced physicians

Chain of command

Frosch, D.L., S. G. May, K. A. Rendel, C. Tietbohl, and G. Elwyn. "Authoritarian Physicians and Patients' Fear of Being Labeled 'Difficult' among Key Obstacles to Shared Decision Making." Health Aff (Millwood), May 2012.

Closing the Gap

Standardize Hardwire within your system

Allow opportunity to ask questions

Reinforce quality Educate and coach Teamwork

Triage Tracking

Improving Transitions of Care: Hand-Off Communications Storyboard. Joint Commission Center for Transforming Healthcare. December 22, 2014. www.centerfortransforming healthcare.org

The Case of Samantha Bishop


Improving Transitions of Care

Outcomes

Patient-family

experience

Provider experience

Patient Safety

Healthcare utilization

Health outcomes


NTOCC Measures Workgroup, 2008. http://www.ntocc.org/

Evaluate your “parking lots”

• Crawl-Walk-Run

• Incidences including near misses

• Information transfer

• Medication reconciliation, falls and other high risk areas

• EMR strengths and weaknesses


Closing Thought

“Let’s manage safety, recognizing how humans are, and stop managing safety the way we wish humans were.” – Alan Quilley

Resources

The Care Transitions Program http://caretransitions.org/tools-and-resources/ Hospital Guide to Reducing Medicaid Readmissions-AHRQ https://www.ahrq.gov/professionals/systems/hospital/medicaaidreadmithuide/medread-ackn.html I PASS the BATON-AHRQ http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/videos/tspassTheBaton/passTheBaton-400-300.html “Improving the Quality of Care and Communication during Patient Transitions: Best Practices for Urgent Care Centers.” www.jointcommission.org

http://caretransitions.org/tools-and-resources/







https://www.ahrq.gov/professionals/systems/hospital/medicaaidreadmithuide/medread-ackn.html



http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/videos/tspassTheBaton/passTheBaton-400-300.html







http://www.jointcommission.org/

Resources

“In the Clinic Transitions of Care.” http://www.med.unc.edu/apselect/files/transitions-of-care Project BOOST-AHRQ http://www.bu.edu/fammed/projectred/toolkit.html Project RED http://www.bu.ed/fammed/projectred/toolkit.html Safer Sign Out-Emergency Medicine Patient Safety Foundation http://safersignout.com/safer-sign-tool-kit/ Sentinel Event Alert: Issue 54 Safe use of health information technology http://www.jointcommission.org/assets/1/18/SEA54.pdf

http://www.med.unc.edu/apselect/files/transitions-of-care





http://www.bu.edu/fammed/projectred/toolkit.html

http://www.bu.ed/fammed/projectred/toolkit.html

http://safersignout.com/safer-sign-tool-kit/







http://www.jointcommission.org/assets/1/18/SEA54.pdf

References

Transitions of Care: The need for a more effective approach to continuing patient care. Hot Topics in Health Care. The Joint Commission. www.thejointcommission.org. Wachter, Robert M. Understanding Patient Safety. New York. The McGraw-Hill Companies, Inc. There and Home Again, Safely: 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions. American Medical Association. 2013. Care Coordination: Executive Summary. ECRI Institute PSO Deep Dive. September 2015. Careers in Medicine. The American Medical Association. Improving Care Transitions. Health Policy Brief. Health Affairs. Robert Wood Johnson Foundation. September 13, 2012. www.healthaffairs.com The Joint Commission: Office of Quality and Patient Safety. Sentinel Event Data: Root Causes by Event Type: 2004 - 3Q 2015. Chicago, IL: The Joint Commission, 2016. Transitions of Care: The need for a more effective approach to continuing patient care. Hot Topics in Health Care. The Joint Commission. www.thejointcommission.org. Starmer et al. Changes in Medical Errors after Implementation of a Handoff Program. New England Journal of Medicine November 6, 2014. www.nejm.org

http://www.thejointcommission.org/

http://www.healthaffairs.com/

http://www.thejointcommission.org/

http://www.nejm.org/

References

. Improving Transitions of Care: Hand-Off Communications Story Board. Joint Commission Center for Transforming Healthcare. December 22, 2014. www.centerfortransforming healthcare.org. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press, 2001. Goopman, Jerome. How Doctors Think. New York, New York: Houghton Mifflin Harcourt Publishing Company, 2007 Specter, Michael. "The Operator." The New Yorker, February 4, 2013 Frosch, D.L., S. G. May, K. A. Rendel, C. Tietbohl, and G. Elwyn. "Authoritarian Physicians and Patients' Fear of Being Labeled 'Difficult' among Key Obstacles to Shared Decision Making." Health Aff (Millwood), May 2012.

patient safety begins in the georgia society for ...teresa mcmillan, rn, msa, cphrn, lhrm, cpps...

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