Innovative Techniques for Physicians to Improve Safety

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Innovative Techniques for Physicians to Improve
Safety

• Tammy Lundstrom, MD
• Detroit Medical Center-Wayne State University
• VP, Chief Quality and Safety Officer

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Improving Patient Safetymeans . . .

• Reducing medical errors.

Reducing patient harm.
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Patient Safety Terminology
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Overview of a Comprehensive Program
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Detroit Medical Center

• 13,000 employees
• 3000 physicians
• 1000 Graduate Medical Residents
• 1000 Medical Students
• Nursing Students
• Pharmacy Students
• PA Students

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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

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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

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Comprehensive Program
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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

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What is a Safety Culture

• And how is it achieved?

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Lessons from a Leader

• Safety is not a priority, its a way of life
• Paul ONeill
• CEO Alcoa Steel
• Treasury Secretary

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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

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Advantage to Focus on near Misses

• No patient harm, therefore no blame
• No guilt
• Focus on prevention
• No fear of litigation

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Disclosure of Unanticipated Outcomes to Patients
and Families
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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)

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Why Disclosure?

• We are our patients 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

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Advocating Disclosure

• American Society for Healthcare Risk Managers
• JCAHO
• AHA
• AMA

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JCAHO

• Standard
• RI.1.2.2 Patients and, when appropriate, their
  families are informed about the outcomes of care,
  including unanticipated outcomes.

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AHA

• Develop an institutional policy or position
  statement on disclosure of unanticipated outcomes
• Differentiate between disclosure of an
  unanticipated outcome and an admission of
  liability
• Determine 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
  organizations policies and procedures covering
  this issue, and consider communications training
  for those charged with disclosing unanticipated
  outcomes
• Specify documentation requirements regarding
  disclosure

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ASHRM

• Each Healthcare institution must develop its 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

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For additional detail on implementation of a
policy on disclosure of outcomes, consistent with
the requirements of this standard
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AMA

• AMA Professional Code of Ethics

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Steps to Follow After Event

• Care for immediate needs of patient
• Preserve evidence (Medical equipment)
• Document in the medical record
• Report (Risk Management)
• Disclose

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Documentation

• Document only the facts of what occurred and
  treatment rendered
• NOT
• Blame
• Subjective feelings, opinions
• Speculation
• Reference to Incident report

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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

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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

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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
  DONT SPECULATE! Offer to speak again as facts
  become known

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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)

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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

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Examples from the Front Lines

• Physician Leadership is Key

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Medication Safety

• Why physicians?

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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

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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

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Physician Education

• Physician Led

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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

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Physician Education Modules

• Sexual Harassment
• Code of Conduct
• Pain Management
• Medical Safety and Incident Reporting
• Restraint Use
• Conscious Sedation
• Infection Control
• Life Safety

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• Moderate Sedation
• for Physicians and
• Licensed Independent Practitioners

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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.

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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

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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 patients 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.

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Moderate Sedation Monitoring Standards

• Level of consciousness
• Monitoring the patients 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.

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Moderate SedationEmergency Equipment

• Pharmacologic Antagonists and resuscitation drugs
• Intravenous access
• Supplemental oxygen
• Advanced airway equipment
• Cardiac defibrillator

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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.

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Sharps Safety

• Why Physicians?

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Physician-Performed TestingRequirements

• Dfn Test personally performed by a physician in
  conjunction with the physical examination or
  treatment of a patient

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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

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PPT

• Post-coital mucous exam
• Potassium hydroxide preparations
• Semen analysis, qualitative
• Synovial fluid for crystals
• Urine dipstick
• Urine sediment microscopy
• Vaginal wet mount microscopy

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Whats 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

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How will you comply?

• Training and documentation
• Reagent control
• No bottles in pockets!!
• House staff? Other trainees?

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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

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Physician Peer review and Patient Safety
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Incident Reports
Incident Occurs
Peer Review -Physician specific practice as it
relates to care of this patient
Root Cause -Process
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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

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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