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Preventing Medical Errors in Physical Therapy

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Preventing Medical Errors in Physical Therapy Carol A. Clayton, Ph.D., PT EXAMPLES from MEDIA Pat McEachern was paralyzed on the right side of her body as a result of ... – PowerPoint PPT presentation

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Title: Preventing Medical Errors in Physical Therapy


1
Preventing Medical Errors in Physical Therapy
  • Carol A. Clayton, Ph.D., PT

2
Objectives
  • Identify two historical factors (either federal
    or state) which contributed to this course being
    required.
  • List two key conclusions of the IOM report, 1999
  • Define Adverse Event, Medical Error, and
    Sentinel Event
  • Explain the RCA and FMEA approaches to problem
    solving
  • Identify error-prone situations in PT
  • Explain the PT/PTAs responsibility for reporting
    medical errors
  • Explain why errors happen and how they can be
    prevented in a PT Dept to insure patient safety
    e.g. documentation, communication,
    pharmacological components, contraindications/indi
    cations.
  • Describe pros and cons for having a voluntary and
    mandatory reporting system
  • Explain the role of the professional associations
    concerning patient safety

3
HAVE YOU EVER HEARD SOME ONE SAY
  • Hospitals are where you go to die.
  • I didnt get better, I got worse.
  • I dont think they knew what they were doing!
  • I couldnt understand a word she said.
  • Get a second opinion!!!
  • I wasnt sick until I went into the hospital

4
Medical Errors have been going on for a long
time patients and health care workers have known
this most are never reported mistakes have been
buried patients have died from preventable
mistakes.
5
  • The health care system is NOT a healthy system!
  • The scope of medical errors and patient safety
    problems has never been documented before.
  • What got the ball rolling to finally take a look
    at the HEALTH CARE SYSTEM?

6
HISTORICAL PERSPECTIVE
  • Clinton-Gore Administration
  • Balance Budget Act of 1997. This was an effort
    to eliminate financial fraud and abuse within
    health care.
  • Many budget cuts in spending
  • Medicare/Medicaid cuts
  • Entitlement was cut
  • Treatments limited to minutes
  • Caps placed on services
  • Gag clauses added

7
HISTORICAL PERSPECTIVE
  • Clinton-Gore Administration (contd)
  • 1997 Advisory Commission on Consumer Protection
    and Quality established. This was an effort to
    improve the quality of health care.

8
HISTORICAL PERSPECTIVE
  • Clinton-Gore Administration (contd)
  • 1998 Quality of Healthcare in America Project
  • The Quality Interagency Coordination Task Force
    (QuIC) established to coordinate quality
    improvement activities in Federal health care
    programs
  • QuIC included the departments of Health and Human
    Services, Labor, Veterans Affairs, Commerce, and
    Defense the Coast Guard the Bureau of Prisons
    and the Office of Personnel Management.

9
HISTORICAL PERSPECTIVE
  • Clinton-Gore Administration (contd)
  • 1998 Quality of Healthcare in America Project
    (Milestone Study)
  • Institutes of Medicine (IOM) became responsible
    for this Project
  • Results of IOM study (published in 1999)
    precipitated many more federal and state
    initiatives and received a lot of Media
    attention.

10
HISTORICAL PERSPECTIVE
  • Clinton-Gore Administration (contd)
  • 1999/2000 The Agency for Healthcare Research and
    Quality (AHRQ) charged with supporting research
    designed to improve the quality of health care,
    reduce its cost, improve patient safety, address
    medical errors, and broaden access to essential
    service.

11
INSTITUTES OF MEDICINE
  • It is the medical arm of the National Academy of
    Sciences.
  • Their Project titled Quality of Health Care in
    America
  • Focus of project medical errors and patient
    safety

12
INSTITUTES OF MEDICINE
  • Reasons for this focus
  • Errors were responsible for an immense burden of
    patient injury, suffering, and death
  • Errors in the provision of health services,
    whether they result in injury or expose the
    patient to the risk of injury, were events that
    everyone agrees just shouldnt happen
  • Errors were readily understandable to the
    American public
  • There was a sizable body of knowledge and very
    successful experiences in other industries to
    draw upon in tackling the safety problems of the
    health care industry
  • The health care delivery system was rapidly
    evolving and undergoing substantial redesign,
    which may introduce improvements, but also new
    hazards.

13
INSTITUTES OF MEDICINE
  • 1999 published report called To Err is Human.
    Building a Safer Healthcare System
  • Results stated 44,000 98,000 people die in
    hospitals each year as a result of preventable
    medical errors. (info Colo, Utah, NY)

14
IOM Results (contd)
  • Adverse events occurred in 2.9 3.7 of the
    hospitals studied. Of these adverse events 6.6
    13.6 resulted in deaths. Fifty percent of these
    adverse events were from preventable medical
    errors.
  • The number of deaths due to medical errors
    exceeds the number of deaths resulting from
    motor-vehicle wrecks (43,458), breast cancer
    (42,297) and AIDS (16,516)

15
IOM Results (contd)
  • Total national costs (lost income, lost household
    production, disability, and health care costs) of
    preventable adverse events are 17 29 Billion.
    Health care costs are over 50
  • Preventable injuries in hospitals affect 3 4
    of patients.

16
IOM Results (contd)
  • The majority of problems were system problems not
    the fault of individuals.
  • A system is a set of interdependent elements
    interacting to achieve a common aim. The
    elements may be both human and non-human
    (equipment, technologies, etc.)
  • Well-oiled machine
  • Dominoes falling

17
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18
IOM RECOMMENDATIONS
  • Establish a national focus on patient safety.
    This is done by
  • Making patient safety EVERYONES responsibility
  • Developing effective mechanisms for
    identifying/dealing with unsafe procedures and
    practitioners
  • Simplifying processes and systems
  • Standardizing processes (intertester/intratester
    reliability)
  • Reporting errors immediately
  • Ensuring no reprisals for reporting
  • Developing a culture of openness and
    communication
  • Implement feedback and learning from mistakes
  • Anticipating the unexpected
  • Respecting human limits

19
IOM RECOMMENDATIONS
  • Identify and learn from errors by establishing a
    nationwide mandatory and voluntary reporting
    system (encourage health care organizations to
    participate)
  • In 2000, Pres. Clinton urged a state-based
    system of reporting medical errors to be phased
    in over time mandatory reporting of the med
    errors resulting in death or serious injury
    voluntary reporting of the other medical
    mistakes.

20
IOM RECOMMENDATIONS (contd)
  • Raise performance standards and expectations for
    improvements with multiple agencies,
    professionals and consumers.
  • Implement safe practices at the delivery level
    and build a culture of patient safety.

21
HISTORICAL SUMMARY
  • Federal Level
  • Presidential Action
  • Advisory Commission
  • Task Force
  • Project (done by IOM)
  • Results of Project (eye-opening)
  • Several Senate Bills

22
  • State Level
  • FS 456.013(7) passed
  • Omnibus Health Care Bill was adopted (SB 1558,
    section 63)
  • Hospitals were to evaluate systems for wrong site
    surgery, wrong patient, wrong procedure, and
    unnecessary procedures.
  • FHA (Florida Hospital Association) organized an
    interdisciplinary Patient Safety Steering
    Committee.
  • Developed practice models for all hospitals to
    incorporate into their patient safety programs
    on Safe Medication Practices, Safe Surgery
    Practice, and Falls Prevention.

23
LAW (Reference Materials)
  • FS 456.013(7)
  • FS 486
  • FAC 64B17 8.002

24
Definitions
25
SAFETY
  • Freedom from accidental injury

26
  • Whether a person is sick or just trying to stay
    healthy, they should not have to worry about
    being harmed by the health system itself. IOM,
    1998

27
MEDICAL ERROR
  • The failure of a planned action to be completed
    as intended or the use of a wrong plan to achieve
    an aim.

28
MEDICAL ERROR
  • Planning use of a wrong plan to achieve desired
    aim
  • Execution failure of a planned action to be
    completed as intended

29
MEDICAL ERROR
  1. Sentinel Events
  2. Adverse Events
  3. Close Calls
  4. Intentional Unsafe Acts

30
A. SENTINEL EVENT
  • Unexpected events resulting in the death or
    serious physical or psychological injury of a
    patient

31
EXAMPLES from MEDIA
  • Betsy Lehman (a health reporter for the Boston
    Globe) died from an overdose during chemotherapy.
  • Willie King had the wrong leg amputated.
  • Ben Kolb (8 y.o.) died from a drug mix-up during
    minor surgery.
  • Six year old boy died when a metal oxygen tank
    was pulled into the MRI.

32
EXAMPLES from MEDIA
  • Dr. Karl Shipman died from the orthopedic surgery
    for a broken wrist. Infection started and
    migrated to spinal column. Complaints of neck
    and back pain lead to prescription for PT. No
    vital signs or lab tests were taken.

33
B. ADVERSE EVENTS
  • Injury caused by medical management rather than
    underlying disease/condition of patient

34
EXAMPLES from MEDIA
  • Pat McEachern was paralyzed on the right side of
    her body as a result of a botched angiogram.
  • Diane Artemis fell after a THR dislocating her
    hip. Fall went unreported. Six weeks later,
    x-rays revealed the problem. Two follow-up
    surgeries were needed. During Rehabilitation,
    hip was mishandled, and became less mobile. More
    surgery and radiation was needed.

35
C. CLOSE CALLS
  • (Sigh of relief, whew, and a silent thank
    you prayer!!!)
  • What could have been a tragedy was averted

36
D. INTENTIONAL UNSAFE ACTS
  • Knowing something is hazardous and could
    compromise the safety of a patient, but is done
    anyway.

37
NEGLIGENCE
  • Failure to provide care for a patient within the
    established standard of care for the profession
    resulting in injury to the patient.

38
MALPRACTICE
  • Incorrect or negligent treatment of a patient by
    persons responsible for health care
  • The patients medical record is used in 80 85
    of malpractice suits to establish treatment given
    and results of care.

39
COMPARATIVE FAULT
  • A legal concept permitting courts to distribute
    the damages to a patient between each negligent
    person involved in the legal action

40
More Examples of MEDICAL ERRORS
  • Wrong medication type
  • Wrong medication dosage
  • Wrong site surgery
  • Misdiagnosis leading to incorrect therapies
  • Misinterpretation of test/lab results
  • Failure to act on abnormal results
  • Equipment failure
  • Infections
  • Misinterpretation of medical orders
  • Conditions of fatigue, stress, and pressure in
    the staff
  • ETC, ETC, ETC

41
BENCHMARKING
  • Comparing your organizations performance with
    others similar to yours

42
ERROR PRONE SITUATIONS
  • Situations, procedures or circumstances during
    which medical errors are increasingly possible

43
PERFORMANCE IMPROVEMENT
  • Continuous effort on the part of the healthcare
    professional to find new and better ways of
    undertaking tasks and procedures.

44
UNDERLYING CAUSE
  • The system or process that allowed an undesirable
    event to occur.

45
HIGH RISK POPULATIONS
  • Elderly patients
  • Patients with cognitive decline
  • Patients with developmental or learning
    disabilities
  • Psychiatric patients
  • Infants and young children

46
Medical Error Settings (JCAHO)
  • General hospital
  • Long Term Care Facility
  • Psychiatric hospital
  • Psych unit (gen. hosp)

47
MEDICAL ERROR SITUATIONS (JCAHO)
  • Op/post-op complications
  • Medication errors
  • ADR Adverse Drug Rxn.
  • Wrong-site surgery
  • Delay in treatment
  • Falls
  • Death/injury due to restraints
  • Transfusion error

48
REMEMBER!!!!
  • A Medical Error is like a mosquito bite instead
    of a plane crashharm comes to one patient at a
    time making the accident less visible and
    possibly even looking insignificant. A plane
    crash results in many getting harmed at one time.
    It gets the immediate attention of everyone.

49
ANALYSIS OF MEDICAL ERRORS
  • Two methods
  • The Root Cause Analysis (RCA)
  • The Failure Mode and Effects Analysis (FMEA) The
    Healthcare Failure Mode and Effects Analysis
    (HFMEA)

50
ROOT CAUSE ANALYSIS
  • Looking for basic and contributing causal factors
  • After the medical error has occurred.
  • Retrospective or hindsight review
  • Monday morning quarterbacking crime scene
    investigations (CSI)
  • Hindsight bias
  • Narrows the focus on the cause without
    considering the whole picture (environmental,
    emotional, political and system issues)

51
FAILURE MODE AND EFFECTS ANALYSIS (FMEA HFMEA)
  • Prospective analysis
  • Systematic method of identifying and preventing
    product and process problems
  • Before problem occurs
  • Tries to anticipate the unexpected
  • Puts the time, money and effort into the design
    of a process up front!

52
PHYSICAL THERAPY
  • Where are we the most vulnerable?
  • The setting
  • The types of patients
  • The types of diagnoses
  • Patient Management
  • PT Department Management and Oversight

53
Discussion
54
LEADERSHIP FUNCTIONS
  • Current accreditation standards from CAPTE
    address the safety issue being incorporated
    within PT/PTA curricula
  • Clinical Performance Instrument (CPI) has a red
    flag designation on the PT/PTA behavior
    reflecting safety
  • Guide to Physical Therapist Practice addresses
    safety throughout the document

55
REMINDER
  • When things get tough, and a medical error occurs
    (or the potential for a medical error is present)
  • THINK OF LUCY
  • And determine the cause system or personnel

56
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