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EDIS: Improving Patient Safety and Reducing Medical Errors

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Title: EDIS: Improving Patient Safety and Reducing Medical Errors


1
EDIS Improving Patient Safety and Reducing
Medical Errors
  • Daniel J. Sullivan, MD, JD, FACEP
  • President, The Sullivan Group

2
Objectives
  • Understand the concept of a risk and safety
    overlay on an ED Information System.
  • Recognized the power of a prompted medical
    record.
  • Understand the potential for an EDIS to improve
    patient safety, reduce medical errors, and reduce
    med mal claims.

3
Case Study 1
  • A 14 year-old male presented to an emergency
    department triage station with a complaint of a
    painful swollen scrotum.
  • The triage practitioner did not recognize the
    significance of the presentation. The patient
    waited in the waiting room for four hours.
  • The patient and his mother left without treatment
    and presented to another hospital that was
    directly across the street.
  • At triage the patient presented his complaint to
    the triage nurse.

4
In this department the triage nurse is prompted
to open a drop down box of seconds to minutes
emergencies.
5
Use of the seconds to minutes drop down turns
the red light green, and the scrotal pain
complaint results in a warning and recommendation
to contact the charge nurse or ED physician.
This is a high risk complaint
6
  • The triage nurse contacted the emergency
    physician within moments of triage. The
    emergency physician examined the patient
    immediately. The patient was in the OR within 30
    minutes of arrival at this institution.
  • The testicle was not viable in this case, but the
    information system assisted in providing timely
    care.

7
Case Study 2
8
Chest Pain TSG Audit
9
(No Transcript)
10
Physician PE Cardiovascular Exam
Note there is no prompt next to the bilateral
blood pressure statements.
11
(No Transcript)
12
Acknowledging this question turns the red light
green and documents that notification has
occurred.
13
Nursing Drop Down List Compliance
14
Nursing Triage Drop Down Compliance by
15
Tracking Board
Color enhancement is a powerful visual stimulus.
The seconds to minutes emergencies are set off
on the tracking board in some unique manner so
the entire department is immediately aware of the
need for attention.
16
History of Documentation Tools
  • Handwriting Dictation
  • CMS creates E M formulas for reimbursement
  • Templates built for billing and coding
  • Electronic medical records
  • Can electronic systems reduce risk and improve
    patient safety?

17
Real-Time Risk Management
  • EM historical approach to managing risk.
  • Peer review
  • Lectures
  • Consider industries that have solved the risk and
    error problem.
  • Hardwire safety into the practice of emergency
    medicine.

18
Data Source for This Discussion
  • TSG Risk Safety Data Base
  • 220,000 high-risk patients
  • Between 10 to 15 risk indicators per patient
  • Over 2.4 million risk indicators
  • Over 300 US hospitals
  • Over 3000 emergency practitioners

19
Examples
  • Abnormal vital signs not repeated at alarming
    rates in our study of 90,000 patients.
  • Risk factors for high-risk disease simply not a
    part of the physician history in our analysis of
    over 60,000 patients.
  • Tendon evaluations completely inadequate in hand
    injured patients.
  • Pregnancy tests not being done on the appropriate
    women.
  • Guaiac evaluations of the stool 20 in 16,000
    abdominal pain patients.

20
Examples
  • Imaging studies not done in obvious cases of
    elderly patients with radiating abdominal pain.
  • Acyclovir not administered to neonates with
    possible herpetic encephalitis.
  • Patients with extraordinary vital sides dying in
    the waiting room.
  • Completely inadequate re-evaluations on high-risk
    patients…

21
National Profile - Vital Sign Evaluation
  • We looked at vital signs in 90,000 patients.
  • 16 of patients with very abnormal vital signs
    are discharged without a single repeat.
  • Extrapolate to the nation. The related morbidity
    and mortality is staggering.
  • Electronic systems can prevent this common
    medical error.

22
Abnormal Vital Sign Solution
23
Abnormal Vital Sign Solution
When looking at Joe Smith, ALWAYS have this
patients vitals on the screen. Color code for
abnormalities.
24
Abnormal Vital Sign Solution
When the nurse or physician attempts to discharge
this patient a vital sign warning appears.
25
  • The practitioner may Continue.
  • But is more likely to re-evaluate vital signs.
  • This system has taken the national average of 16
    and reduced it to near 0.
  • Hardwire a solution into the ED and the problem
    goes away.
  • Dramatic reduction in medical errors.

26
National Profile EM Risk Factor Analysis
  • The National Profile of EM care reveals grossly
    inadequate risk factor analysis for
  • Thoracic Aortic Dissection
  • Pulmonary Embolism
  • Abdominal Aortic Aneurysm
  • Subarachnoid Hemorrhage
  • Torsion Testicle
  • Ectopic Pregnancy

27
Risk Factor Audit
28
Prompting Risk Factor Solution
29
Risk Factor Audit Cycle 1
Risk Factors Across the Emergency Department
30
Risk Factor Audit Cycle 2
Risk Factors Across the Emergency Department
31
Risk Factors Cycle 3 (12/7/04)
Risk Factors Across the Emergency Department
32
Prompting - Meeting the Standard of Care
33
Chest Pain Patient gt 30 Years of Age
34
Chest Pain Patient gt 30 Years of Age
35
Adult Headache Patients
36
Adult Headache Patients
37
Compliance by Medical Record Type
38
Chest Pain Risk Indicators-Dictation
BEFORE PROMPTS
39
Chest Pain Risk Indicators
AFTER PROMPTS
40
Laceration Risk Indicators-Dictation
BEFORE PROMPTS
41
Laceration Risk Indicators
AFTER PROMPTS
42
Children With Fever Risk Indicators-Dictation
BEFORE PROMPTS
43
Children With Fever Risk Indicators
AFTER PROMPTS
44
Demonstrate Analysis of the Differential Diagnosis
45
Immediate Access to Risk Stratification Tools,
Orders, Protocols
46
Warning Icon Practice Documentation Aids
47
Physician HPI Chest Pain
When the practitioner clicks on a Key Information
Icon, a pop-up window will appear with the Key
Point information.
48
Key Information
49
Discharge Instructions
  • Huge quality and risk issue
  • Transfer responsibility for care
  • Electronic systems clearly superior
  • Medical record must contain a copy
  • Discharge process should be signed by patient or
    responsible individual

50
What Can We Accomplish?
  • Make a wish list
  • Demonstrate that medical practitioners and nurses
    are meeting the standard of care.
  • Practice support (e.g. risk factors).
  • Key information support.
  • Abnormal vital sign discharge 0
  • Communication with the ED team.

51
What Can We Accomplish?
  • Communicate a differential diagnosis.
  • Communicate that a high-risk diagnosis was not
    present during your watch.
  • Re-Evaluation (consider the possibilities)
  • Automatically monitor change in condition over
    time.
  • Monitor the waiting room.

52
What Can We Accomplish?
  • Link the various geographical elements of the
    new mega ED design.
  • Meet JCAHO requirements.
  • Throughput
  • Core Measures
  • Reporting opportunities.
  • Evidence based medicine support.
  • On-line risk stratification.

53
What Can We Accomplish?
  • On-line order sets.
  • Immediate access to old medical records.
  • Create the medical record real time.
  • No lost charts.

54
HCA, Inc. EM Risk Initiative
  • HCA initiated the EM Risk Initiative in 2002 in
    200 hospitals.
  • The number of EM related claims filed against
    HCA has dropped by 38 in four years.

Business Insurance April 18, 2005, p 26 27.
55
(No Transcript)
56
Fewer Misdiagnosis Claims
57
Impact of ED Risk Audit
Aggregate Audit Scores
58
Houston EM Group
  • Eleven EDs.
  • Over 150 EM physicians.
  • 325,000 annual visits.
  • Started EMRI in 2001.
  • The following data was presented at a national
    risk meeting by CEO.

59
Claims/Lawsuits All Facilities Compiled By Year
of Occurrence
60
Claims/Lawsuits All Facilities Indemnity Paid
1998 2005 Compiled By Year of Occurrence
61
(No Transcript)
62
Recommendations
  • Recognize that electronic does not better.
  • Make a check list.
  • Must do site visits.
  • Beware vaporware.
  • Report structure is critical.
  • Open space to individualize.

63
Recommendations
  • Reporting structure is critical.
  • Training and customer support is a risk issue.
  • Preparation for transition.
  • Enjoy the ride!

64
The End
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