Patient Safety: How You Can Prevent Medical Errors

1
Patient Safety How You Can Prevent Medical
Errors

• Arpana R. Vidyarthi, MD
• Associate Professor of Clinical Medicine
• Director of Quality and Safety Programs, GME

2
Why Are You Here?

• my time in the developing world led me to
• the scientific exchange that I experienced in
  the lab
• UCSFs reputation

Help People---Stomp Out Disease
First Do No Harm
3
The Institute of Medicine 44,000 98,000
preventable adverse events yearly
Exceeds those who die from highway accidents,
breast cancer, and aids
4
Medical CareThen and Now
5
First Do No Harm

• Safety of patients is our priority
• .and we could be doing a better job!

6
Individual Errors Are Common, And Expected

• Slips
• Errors involving semi-automatic routines daily
  activities
• exacerbated fatigue, competing tasks

• Mistakes
• Errors in interpretation, misapplication of
  cognitive rules
• more likely in new or unusual situations

7
The Swiss Cheese Model of Major Accidents
Errors
Human Glitch
Flawed Systems
Patient Harm
James Reason, Human Error
8
What Type of Human Glitches Cause Harm?
JCAHO Sentinel Event Statistics, 2004
9
JCAHO Sentinel Event Statistics, 2004
10
JCAHO Sentinel Event Statistics, 2004
11
What is Our Goal?

• Patient Safety

• Freedom from accidental injury due to medical
  care, or medical errors

12
So What Can You Do About It?
Its Not Rocket Science

• Use Communication Tools
• Be Conscientious of Signouts
• If you see something wrong, tell someone

13
Communication Tools
So 1 order moo-shoo, fried riceand what kind of
milk?

• Read back for all verbal orders
• Standardization for order sets
• OR Time-Outs
• SBAR

Can I have an order of moo-shoo pork, fried rice,
and milk?
14
Case Presentation Edith presents with SOB
TimeLine
7AM
6AM
5AM
4AM
3AM
2AM
1AM
12AM
8AM
Shortness of Breath Sent for CXR
Labs Admit Settled on ward
Edith in ED ED Resident
Shift Change ED Resident
Night Float Resident
Medicine ward Medicine Resident
15
Day 1
TimeLine
2 PM
10AM
6AM
2AM
10PM
6PM
2PM
10AM
6PM
Decompen-sates Edith in ICU Edith in
ICU Edith Stable Edith Stable
Transfer to ICU On Call Medicine Resident
Resident 5 goes to clinic Cross coverage Resident
Resident returns
Resident goes home Day Float Resident
Day Float goes home On call intern
16
Day 2
TimeLine
12 PM
8AM
6AM
2AM
10PM
6PM
2PM
10PM
4PM
Edith in ICU Shortness of Breath/
Intubated Intubated Stable Extubated
On Call intern sign out Intern Night Float
Resident Returns
Resident continues
17
The first 48 hours of Ediths stay.
Total Residents in Charge of Care 9 Total
Sign-outs 10

• Resident Do you remember us Edith, we are the
  doctors taking care of you?
• Edith Uh.no?
• Resident 5 to intern She seems altered. Lets
  get a stat head CT.

18
Why So Many Handoffs Today?

• ACGME duty hour limitations
• 80 hours per week
• 30 hours continuous
• 24 hours off per month

• Practicing physicians
• Group practices cross-coverage
• Hospitalists

4000 Handoffs Daily, 1.5 Million Handoffs per
Year
19
Housestaff Experiences

• Perceptions

• Impacts

• handoffs are dangerous
• A common suboptimal care practice
• 59 report patient harm
• Increased errors from discontinuity

• Clinical
• Delayed test ordering
• Increased in-hospital complications
• Increased medication errors
• Presumed increase in length of stay

Vidyarthi, JGIM, 2006Kitch, Jt Comm J Qual
Patient Safe,2008 Irani, Surgery, 2005
20
Discontinuity and Patient Harm

• Most significant risk for an adverse event
• cross-covering MD

Petersen, L. A. et. al. Ann Intern Med
1994121866-872
21
Handoff Best Practices
Best Practice Guidelines

• University Health Consortium
• Position Papers
• IM, ER, Surgery, Hospital Medicine
• Society of Hospital Medicine
• Joint Commission

Standardize
Do itwell
UHC,2006 Solet, Academic Med, 2005 Kemp, Arch
Surg, 2008 Vidyarthi, JHM 2006 Arora, JHM
pending Joint Commission, 2009
22
(No Transcript)
23
(No Transcript)
24
Communication Channels
www.agilemodeling.com/essays/communication.htm
25
Think About What You Would Want To Know

• Who
• What
• Administrative Data
• Problem list
• To Do List
• Nuance
• Where

26
What Can You Do To Diminish Harm at Signouts?

• Take it seriouslywe do
• Use standardized toolsthey work
• Verbally sign outit matters
• Role modelremember yesterday

27
Individual Errors Are Common, And Expected

• Slips
• Errors involving semi-automatic routines daily
  activities
• exacerbated fatigue, competing tasks

• Mistakes
• Errors in interpretation, misapplication of
  cognitive rules
• more likely in new or unusual situations

28
So What Do You Do When?

• Report problems
• Incident reports/near miss reports
• Let us know arpana_at_medicine.ucsf.edu,
• Tell your chief residents!
• Dont fear the RCA

29
Case Review To Fix the System

• Root Cause Analysis

• Case Review-Peer Review

• Medical center level
• Multi-disciplinary
• Clinical Events Oversight Committee
• Systematic review of the events including
  participants with actions

• Department/division based
• Single discipline
• M and M/Peer Review/Case Review
• Discussion and review by peers

30
Engage the Process

• You are the one with the knowledge events
• Clinical
• Operational
• Systems
• You are the one with knowledge solutions
• Experience
• Feasibility
• Culturally applicable

31
Safety and Quality Today

• Safety

• Quality

• Freedom from accidental injury due to medical
  care, or medical errors

• The degree to which health services for
  individuals and populations increase the
  likelihood of desired health outcomes and are
  consistent with current professional knowledge

32
And on the Quality Front
McGlynn, E. A. et al. N Engl J Med 2003
33
UCSF Programs to Improve Quality

• Curriculum in your department
• Opportunities for Q/S projects
• Resident engagement on committees
• Patient Care Fund
• Resident Quality and Safety Committee

34
UCSFMC/GME Incentive Program
35
Program Specific Incentives

• Anesthesia
• Increase rate of prophylactic antibiotics
• Dermatology
• Decrease clinic wait times
• EM
• Increase PCP communication
• Peds
• Asthma action plans

• Neuro
• Improve swallow exams on stroke pts
• Medicine
• Increase PCP communication
• Neurosurgery
• Ontime start in the OR
• ObGyn
• Improve DM orders
• Radiology
• Critical results reported

400 each/Total 1200
36
Safety and Quality are About Systems
Think of your doctors and nurses as actors in a
grand play. Sure, the play is different when
King Lear is played by Sir Laurence Olivier or
Robin Williams. But Lear dies in both stagings.

Internal Bleeding, Wachter and Shojania
37
Safety and Quality are About Systems
Think of your doctors and nurses as actors in a
grand play. Sure, the play is different when
King Lear is played by Sir Laurence Olivier or
Robin Williams. But Lear dies in both stagings.
If we want the patient to live, we must change
the script!
Internal Bleeding, Wachter and Shojania
38
You Can Change The Script

• Prioritize safety in your everyday work
• Use communication tools
• Signout patients with care
• Report problems you see
• Ask for help!

• Think about the quality of care provided
• Engage the systems

First Do No Harm
Help People---Stomp Out Disease
39
THANKS