A modest proposal: Teaching Patient Safety in the Medical School Curriculum

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A modest proposal Teaching Patient Safety in the
Medical School Curriculum

• Robert Boorstein, MD, PhD
• Bellevue Hospital Center, NYU School of Medicine

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Case 1 A 50 y.o. man with CML

• A bone marrow specimen is sent for cytogenetic
  analysis. The cytogeneticist reports a pattern
  consistent with advanced AML and 2 X
  chromosomes, and no Y chromosome. Why was the
  test performed, and what is the likely cause of
  this result?
• From 4th year selective, Rational Utilization
  of the Clinical Laboratory, NYU School of
  Medicine.

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Revolutions in Medical Education

• Scientific Basis of Medical Practice
• Analytical Reasoning
• Clinical Investigation
• Underlying Moral Basis

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Revolutions in Medical Education II

• Primacy of Doctor Patient interaction
• Patient centric, not disease centric
• Social context of disease
• Access to care
• Patient diversity
• Compassion, empathy
• Limits to physicians abilities

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Physicians must be altruistic!

• For its part the medical school must ensure that
  before graduation a student will have
  demonstrated, to the satisfaction of the faculty,
  the following
• Knowledge of the theories and principles that
  govern ethical decision making, and of the major
  ethical dilemmas in medicine, particularly those
  that arise at the beginning and end of life and
  those that arise from the rapid expansion of
  knowledge of genetics
• Compassionate treatment of patients, and respect
  for their privacy and dignity
• Honesty and integrity in all interactions with
  patients families, colleagues, and others with
  whom physicians must interact in their
  professional lives
• An understanding of, and respect for, the roles
  of other health care professionals and of the
  need to collaborate with others in caring for
  individual patients and in promoting the health
  of defined populations
• A commitment to advocate at all times the
  interests of ones patients over ones own
  interests
• An understanding of the threats to medical
  professionalism posed by the conflicts of
  interest inherent in various financial and
  organizational arrangements for the practice of
  medicine.
• The capacity to recognize and accept limitations
  in ones knowledge and clinical skills, and a
  commitment to continuously improve ones
  knowledge and ability

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• msop1.pdf

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Topics missing from MSOP

• Patient Safety
• Practice Guidelines
• Clinical Protocols
• Medical Errors
• Risk Reduction
• Engineering
• Training

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LCME Educational Objectives

• Content. The curriculum must include behavioral
  and socioeconomic subjects, in addition to basic
  science and clinical disciplines. It must include
  the contemporary content of those disciplines
  that have been traditionally titled anatomy,
  biochemistry, genetics, physiology, microbiology
  and immunology, pathology, pharmacology and
  therapeutics, and preventive medicine.
  Instruction within the basic sciences should
  include laboratory or other practical
  opportunities for the direct application of the
  scientific method, accurate observation of
  biomedical phenomena, and critical analysis of
  data. Technical revision approved June 2006,
  effective immediately.
• Liaison Committee on Medical Education Home Page
• LCME FS Text.htm

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• ToErr-8pager.pdf

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100,000 lives campaign

• Institute for Health Initiatives

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100,000 Lives Campaign Objectives
(December 2004 June 2006)

• Save 100,000 lives
• Enroll more than 2,000 hospitals in the
  initiative
• Build a reusable national infrastructure for
  change
• Raise the profile of the problem (variability in
  the quality of American health care) - and our
  proactive response

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The 100,000 Lives Campaign Scorecard

• An estimated 122,300 lives saved by participating
  hospitals
• Over 3,100 hospitals enrolled
• Over 78 of all discharges
• Over 78 of all acute-care beds
• Over 85 of participating hospitals sending IHI
  mortality data
• Participation in Campaign interventions
• Rapid Response Teams 60
• AMI Care Reliability 77
• Medication Reconciliation 73
• Surgical Site Infection Bundles 72
• Ventilator Bundles 67
• Central Venous Line Bundles 65
• All six 42

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An Introduction to the 5 Million Lives Campaign

• December 12, 2006

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The Platform

• The six interventions from the 100,000 Lives
  Campaign
• Deploy Rapid Response Teamsat the first sign of
  patient decline
• Deliver Reliable, Evidence-Based Care for Acute
  Myocardial Infarctionto prevent deaths from
  heart attack
• Prevent Adverse Drug Events (ADEs)by
  implementing medication reconciliation
• Prevent Central Line Infectionsby implementing a
  series of interdependent, scientifically grounded
  steps
• Prevent Surgical Site Infectionsby reliably
  delivering the correct perioperative antibiotics
  at the proper time
• Prevent Ventilator-Associated Pneumoniaby
  implementing a series of interdependent,
  scientifically grounded steps

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The Platform

• New interventions targeted at harm
• Prevent Pressure Ulcers... by reliably using
  science-based guidelines for their prevention
• Reduce Methicillin-Resistant Staphylococcus
  aureus (MRSA) Infectionby reliably implementing
  scientifically proven infection control practices
• Prevent Harm from High-Alert Medications...
  starting with a focus on anticoagulants,
  sedatives, narcotics, and insulin
• Reduce Surgical Complications... by reliably
  implementing all of the changes in care
  recommended by the Surgical Care Improvement
  Project (SCIP)
• Deliver Reliable, Evidence-Based Care for
  Congestive Heart Failureto reduce readmissions
• Get Boards on Board.Defining and spreading the
  best-known leveraged processes for hospital
  Boards of Directors, so that they can become far
  more effective in accelerating organizational
  progress toward safe care

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The Platform

• plus numerous other interventions that hospitals
  must introduce in order to contribute to meeting
  our aim.

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Joint Commission National Patient Safety Goals

• http//www.jointcommission.org/PatientSafety/Natio
  nalPatientSafetyGoals/

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2007 Critical Access Hospital and Hospital
National Patient Safety Goals

• Goal 1. Improve the accuracy of patient
  identification.
• Goal 2. Improve the effectiveness of
  communication among caregivers.
• Goal 3. Improve the safety of using medications.
• Goal 7. Reduce the risk of health
  care-associated infections.
• Goal 8. Accurately and completely reconcile
  medications across the continuum of care.

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Key Concept Patient Safety, and the clinicians
role in improving patient safety
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Medical School Objectives Project

• For its part the medical school must ensure that
  before graduation a student will have
  demonstrated, to the satisfaction of the faculty,
  the following
• The ability to understand the physicians role
  as a member of a team delivering care within a
  local clinical care environment (micro-system)
• The ability to integrate information technology
  into the improvement of patient care
• The ability to describe the principles of a
  quality improvement initiative that maximizes
  patient safety, despite barriers and variability
  in the practice environment
• The understanding of, by way of direct
  participation in the design, implementation and
  testing of change for the improvement of patient
  care
• The ability to learn from ones own practices
  and corresponding efforts to improve them
• AAMC/2001 Report V - Contemporary Issues in
  Medicine Quality of Care 7

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A paradox

• Despite ongoing changes in curriculum, and
  intensive introspection and self study, medical
  education is lagging behind medical practice
• Medical Schools need to produce physicians at the
  forefront (or at least not the rearguard) in the
  change in medical practice.
• Changes that are needed do not fit neatly into
  the attitudes, knowledge, skills, behaviors
  framework

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Values for Medical Practice in the 21st century

• Results oriented (not process)
• Measurable
• Accountable (to society, not just to the
  profession or to patients)
• Redundancy
• Transparency
• Embracing of training
• Information dependent
• Risk reduction
• Error prevention
• Primacy of systems, not individual judgment

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Words convey values

• Good
• Problem Solving
• Reasoning
• Evidence based medicine
• (interpretation of literature)
• Thinking like a physician
• Physician autonomy
• Reading the literature

• Bad
• Cook-book medicine
• Rote Learning
• Training
• Repetition
• Non-physician oversight
• Choreographed
• Stereotyped
• Protocol
• Standardization
• Following the literature
• Documentation

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What is now being taught

• National Patient Safety Goals
• 100,000 Lives Campaign
• Medical School Objective Project
• Very little systematic coverage of medical
  errors, patient safety, and principles of medical
  systems, in the medical curriculum

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Where to teach

• Ideally, day one.
• Ideally, everywhere
• Second year curriculum
• 4th year curriculum
• Case based approaches are ideal for these issues.

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Second year pathology

• Rationale and use of clinical algorithms
• Importance of precise communication
• Introduction to National Patient Safety goals

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4th year selective in Utilization of the
Clinical Laboratory

• 2 weeks
• 2 hours /day
• 3 cases/day
• 12 students per section
• All teaching case based, student led.
• Initial and final evaluation using audience
  response monitors

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Case 3 A 42 year old man with adenocarcinoma of
the GE junction

• A patient complains of upper GI discomfort. The
  patient is endoscoped, and a small biopsy
  obtained from the GE junction. After much
  debate, the sample is diagnosed as
  adenocarcinoma. The patient undergoes definitive
  surgery. Upon analysis, no tumor is found in the
  resected stomach.
• How do you explain this. What do you tell the
  patient.

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Case 4 A 65 year old man being treated with
coumadin

• A patient comes to clinic, and you suspect the
  coumadin dose is much too high. You draw a
  PT/PTT and sent it to the lab STAT. Two hours
  later, you call the lab, and they tell you that
  the specimen is being processed. You call back
  two hours later and they tell you the same thing.
• What do you do?

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4th year selective in Utilization of the
Clinical Laboratory

• Integration of issues related to patient safety,
  utilization, reliability, algorithm development,
  communication, reporting and cost into
  discussions of clinical utility and underlying
  biomedical principles
• Begin to cover the MSOP Quality of Care goals

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Future Directions

• A patient safety curriculum, from medical school
  through residency
• Assessment of curriculum efficacy