Primum Non Nocere: How to Protect You and Your Patients

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Primum Non Nocere How to Protect You and Your
Patients

• Nicholas Testa, MD FACEP
• Associate Medical Director, LACUSC
• Assistant Professor of Emergency Medicine

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Goals

• Understand the high risk areas in healthcare
• If confronted with an adverse event know the
  basic
• principles of how to respond
• Become familiar with a few of the basic patient
  safety
• techniques that will be expected of you while in
  the
• clinical areas at LACUSC

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The Facts on Medical Errors

• 98,000 hospitalized patients in the United
  States die each year as a result of medical
  errors
• It is estimated that 28,000 deaths occur in
  hospitals secondary to central line infections
  per year
• One adverse drug event occurs for every 20 drugs
  that are administered
• 42 of Americans say that they have been
  involved in a medical error

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Organizations Involved in Patient Safety

• Multiple organizations have become part of the
  discussion on medical errors and patient safety
• Institute for Healthcare Improvement (IHI)
• 5 Million Lives Campaign
• The Joint Commission (TJC)
• National Patient Safety Goals
• Center For Medicare and Medicaid Services (CMS)
• No reimbursement for hospital acquired events
• California Department of Public Health (CDPH)
• Never 28 events
• WHO, CDC, AHRQ etc.

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National Patient Safety Goals The Joint
Commission, 2010

1. Identify patients correctly
2. Improve staff communication
3. Use medicines safely
4. Prevent infections
5. Check patient medicines
6. Identify patient safety risks
7. Prevent wrong site, wrong procedure, wrong
   patient surgeries

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• A smart man learns from his own mistakes but a
  truly wise man learns from the mistakes of
  others
• - Proverbs

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Case 1 Thoracentesis, you did what?

• 8/11/09
• Patient is a 58 y/o Korean male with a hx of
  Hepatitis B Cirrhosis x 25 years, DM Type II X 10
  years.
• Patient presented to his clinic appointment
  where he was evaluated and directly admitted to
  the medicine service to r/o hepatocellular
  carcinoma and spontaneous bacterial peritonitis.
• Admitting medicine team evaluated the patient
  and decided that a diagnostic thoracentesis was
  indicated to evaluate a right sided pleural
  effusion.

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Case 1 Thoracentesis, you did what?

• 8/13/09 1640
• Second year resident (SC) consented the patient
  for a Thoracentesis.
• SC had not done the approved number of
  thoracenteses (5) to perform the procedure
  independently.
• SC sought assistance and supervision. He
  initially called his senior resident but he was
  not available to assist.
• SC made several additional calls to other senior
  residents before he identified a willing third
  year resident on another team to supervise the
  procedure.

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Case 1 Thoracentesis, you did what?

• Resident RB came to the bedside to supervise the
  procedure. RB states that SC was very confident
  about the procedure so he did not anticipate
  any difficulty. RB was focused on the
  residents technique and did not recheck
  laterality.
• Prior to RBs arrival SC reviewed the film and
  prepared the patient for the procedure. SC did
  not re-review the films with RB.
• Prior to initiating the procedure SC stepped out
  of the room to gather additional supplies. When
  he returned the patient had been repositioned by
  RB.
• SC percussed both the left and right chest wall
  and believed there was fluid on the left side of
  the chest.
• 1700
• SC initiated the procedure on the left chest.

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Case 1 Thoracentesis, you did what?

• Three attempts were made without any output
  (this was done by both SC and RB). The residents
  determined that the effusion must be loculated
  and stopped the procedure.
• The patient then advised the physicians that the
  effusion was on the right side and requested that
  the other side be tapped.
• SC immediately informed patient that the
  thoracentesis had been done on the incorrect
  side.
• CXR and EKG were done and the patient was placed
  on continuous pulse Ox monitoring. The Attending
  physician (DR) was called and informed about the
  event.
• Approximately 1830
• The attending went to the patients bed side,
  evaluated the patient and discussed the event
  with the family in detail.

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Event Type Wrong Sided Procedure

• Universal Protocol - 3 Step process to prevent
  wrong side procedures
• Step 1 Pre Procedural Verification
• Verify the needed equipment, review any needed
  studies, discuss and consent patient for
  procedure
• Step 2 Mark the site
• Must be done my a licensed person performing or
  supervising the procedure
• Step 3 Time Out
• Immediately prior to initiating the procedure
  all members of the team participate in the time
  out and confirm
• 1) Correct Patient
• 2) Correct Location
• 3) Correct Procedure

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There is nothing wrong with saying Im sorry

• Hospital policy expects that any untoward event
  be disclosed to the patient/family
• Resources on call 24/7 to assist with any adverse
  event
• Risk Management - [phone]
• Key components to any disclosure
• 1) Initiate the disclosure in a timely fashion
• 2) Apologize
• 3) Take the patients perspective
• 4) Clear communication of the event
• 5) Cultural sensitivity

Sorensen R, Iedema R, Piper D, Manias E, Williams
A, Tuckett A Expect. 2010 Jun13(2)148-59. Epub
2009 Oct 5. Disclosing clinical adverse events to
patients can practice inform policy?.
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Case 2 Ophthalmology Clinic On Any Given Day

• March 12, 2010 Approximately 1230
• Patient Maria Gonzalez presents to the
  Ophthalmology clinic for
• eye exam and possible laser coagulation of
  retinal hypervascularity.
• 1420
• Ophthalmology resident walks into the waiting
  room and calls for
• patient Maria Gonzalez. The patient follows the
  resident into the
• exam room and has her eyes dilated, is examined,
  has significant retinal
• hypervascularity.
• 1450
• The resident consents the patient for laser
  coagulation and proceeds to
• perform the procedure without complications.

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Case 2 Ophthalmology Clinic On Any Given Day

• 1630
• After a short observation period the patient is
  discharged in the
• care of her family
• 1730
• The resident sees the last patient of the day and
  starts to finish
• charting
• 1810
• A Patient comes to the nursing desk stating I am
  Maria Gonzalez
• and I was never called, when am I going to see
  the doctor?
• 1945
• Event entered into Patient Safety Net (PSN)

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Patient Identification - Use Two Patient
Identifiers

• LACUSC Medical Center maintains policy and
  procedure to confirm correct patient
  identification
• Must utilize 2 patient identifiers
• 1) Name
• 2) Date of birth
• 3) Address
• 4) Social Security number

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Patient Safety Net

• Online system used to report any patient-related
  concern
• No log on needed, accessible to anyone at the
  medical center and
• legally protected from outside review
• Reviewed on a daily basis by LACUSC risk
  management with
• follow up on all events as needed

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Case 3 - United Airlines Flight 173

• December 28th, 1978
• Just outside of Portland, OR UA Flt 173 (189
  passengers) was
• approaching for landing.
• When the landing gear was lowered, only two of
  the green landing
• gear indicator lights came on.
• The Captain aborted the landing and the plane
  circled in the vicinity
• of Portland while the crew investigated the
  problem.

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Case 3 United Airlines Flight 173

• December 28th, 1978
• Over the course of the hour the first officer
  makes intermittent
• reference to the fuel status, but the Captain
  stays focused on the
• landing gear and does not acknowledge the crews
  inquiries.
• The crew follow the Captains direction and
  stayed focused on the
• landing gear problem.

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Case 3 Flight 173
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Crew Resource Management

• The supervisor-subordinate relationship has a
  significant value but
• it can undermine safety
• The Captain of the ship can still be the Captain,
  but every voice
• has its value
• How to communicate
• Address them professionally and directly
• State your concern while owning your emotions
• State the problem as you see it
• State a solution
• Obtain agreement

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Speaking Up

• Fear of impacting your relationship with your
  senior or attending
• Insecurity in the hospital due to unfamiliar
  systems and resources
• What you can do
• 1) Talk to your attending
• 2) Call risk management - [phone]
• 3) Enter your concern in the Patient Safety Net
  (PSN)
• 4) Contact me - [phone]
• 5) Contact someone at the medical school

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Case 4 The Costa Concordia

• January 20th, 2012 the Costa Concordia is
  cruising through the Tyrrhenian Sea off the west
  coast of Italy
• 942pm the captain veers the ship towards the
  island of Giglio. The ships chief maître d, was
  a native of Giglio and had asked the captain to
  perform a salute
• 945pm the midsection of the ship struck a rock
  ripping a 50 foot gash into the hull
• 4200 people were on board the ship

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Case 4 Moments After

• Three critical errors
• Going too fast (15knots)
• Navigating by sight, not charts or radar
• Talking on the phone
• 1012 the first SOS call comes in from a
  passenger
• 1016 the coast guard contacts the captain of the
  Costa Concordia who denies any significant damage
• 1030-1040 the ship runs aground
• 1058 the captain gives the abandon ship order
• 1242 the captain was on a life boat while 100s
  of passangers and crew were still on the ship
• Captain weve abandoned ship
• Coast Guard Youve abandon ship?!
• Captain uhwe were thrown into the ocean

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The moments after

• You will not be judged (entirely) by your error,
  you will be judged by how you handle yourself
  immediately after the event
• Be honest without being arrogant or stupid
• Do not admit (or document) fault or blame until
  you are clear as to what happened

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The Second VictimBMJ 2000320726-727

• The culture of medicine encourages that we learn
  from our errors - the patients that we carry with
  us the longest, and feel that we owe the greatest
  debt to are the ones that we harmed
• Physicians-in-training tend to think of many of
  the patient safety recommendations as an after
  thought until they encounter an event - then
  their opinion quickly changes

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Goals

• Understand the high risk areas in healthcare
• If confronted with an adverse event know the
  basic
• principles of how to respond
• Become familiar with a few of the basic patient
  safety
• techniques that will be expected of you while in
  the
• clinical areas at LACUSC