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

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


1
A modest proposal Teaching Patient Safety in the
Medical School Curriculum
  • Robert Boorstein, MD, PhD
  • Bellevue Hospital Center, NYU School of Medicine

2
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.

3
Revolutions in Medical Education
  • Scientific Basis of Medical Practice
  • Analytical Reasoning
  • Clinical Investigation
  • Underlying Moral Basis

4
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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6
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

7
  • msop1.pdf

8
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9
Topics missing from MSOP
  • Patient Safety
  • Practice Guidelines
  • Clinical Protocols
  • Medical Errors
  • Risk Reduction
  • Engineering
  • Training

10
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

11
  • ToErr-8pager.pdf

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14
100,000 lives campaign
  • Institute for Health Initiatives

15
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

16
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

17
An Introduction to the 5 Million Lives Campaign
  • December 12, 2006

18
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

19
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

20
The Platform
  • plus numerous other interventions that hospitals
    must introduce in order to contribute to meeting
    our aim.

21
Joint Commission National Patient Safety Goals
  • http//www.jointcommission.org/PatientSafety/Natio
    nalPatientSafetyGoals/

22
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.

23
Key Concept Patient Safety, and the clinicians
role in improving patient safety
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26
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

27
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

28
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

29
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

30
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

31
Where to teach
  • Ideally, day one.
  • Ideally, everywhere
  • Second year curriculum
  • 4th year curriculum
  • Case based approaches are ideal for these issues.

32
Second year pathology
  • Rationale and use of clinical algorithms
  • Importance of precise communication
  • Introduction to National Patient Safety goals

33
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

34
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.

35
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?

36
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

37
Future Directions
  • A patient safety curriculum, from medical school
    through residency
  • Assessment of curriculum efficacy
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