Medical Errors and Patient Safety for Medical Educators - PowerPoint PPT Presentation

Loading...

PPT – Medical Errors and Patient Safety for Medical Educators PowerPoint presentation | free to download - id: 841b6-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Medical Errors and Patient Safety for Medical Educators

Description:

New York Medical College/Saint Joseph's Medical Center. Department of Family Medicine ... Academic Medicine October 2002. Medical Errors/Patient Safety ... – PowerPoint PPT presentation

Number of Views:911
Avg rating:3.0/5.0
Slides: 30
Provided by: LindaZ9
Learn more at: http://www.nymc.edu
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Medical Errors and Patient Safety for Medical Educators


1
Medical Errors and Patient Safety for Medical
Educators
  • Joseph L. Halbach, M.D., M.P.H.
  • Associate Professor and Chairman
  • Department of Family Medicine
  • New York Medical College
  • 2003 - 2004

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
2
Medical Errors/Patient Safety
  1. Why is this topic important for Medical
    Educators?
  2. What is currently being taught and who is
    teaching it?
  3. What do we recommend should be taught and how?

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
3
Medical Errors/Patient Safety
  • I. Why is this topic important for medical
    educators?

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
4
Medical Errors/Patient Safety
  • Because this topic has rapidly become HOT since
    the IOM Report, embraced by the media,
    government, industry, and private groups.
  • But less rapidly by many physicians.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
5
Medical Errors/Patient Safety
  • Pre-1999
  • Hilfiker, D Facing our Mistakes
  • NEJM 1984
  • Harvard Medical Practice Study 1991

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
6
Medical Errors/Patient Safety
  • Pre-1999
  • Anesthesia Patient Safety Foundation
  • The Mid 1990s Incidents

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
7
Medical Errors/Patient Safety
  • The IOM Report NOV 1999
  • (The Institute of Medicine of the National
    Academy of Sciences)
  • 44,000 98,000 deaths annually in US hospitals
    due to error.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
8
Medical Errors/Patient Safety
  • Post IOM
  • The Patient Safety Movement
  • Media
  • Government
  • Industry
  • Professional Associations
  • Joint Commission
  • Medical Literature

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
9
Medical Errors/Patient Safety
  • GOVERNMENT
  • Agency for Healthcare Research and Quality
    (AHRQ)
  • July 2001 Making Healthcare Safer A Critical
    Analysis of Patient Safety Practices
  • October 2001 - 50 Million grant funding

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
10
Medical Errors/Patient Safety
  • INDUSTRY
  • The Leapfrog Group
  • Require hospitals to adopt computerized physician
    order entry.
  • Steer patients to hospitals/doctors with high
    volume of high-risk procedures.
  • Require ICUs to be staffed with critical care
    specialists.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
11
Medical Errors/Patient Safety
  • Professional Associations
  • National Patient Safety Foundation (AMA)
  • National Center for Patient Safety (VA)
  • Institute for Healthcare Improvement
  • (funding from RWJ)
  • National Quality Forum (NQF)
  • Many organizations devoted to medication errors.
  • Britain, Australia, Canada and other countries
    have similar powerful movements.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
12
Medical Errors/Patient Safety
  • INSTITUTIONS
  • Joint Commission July 2001
  • New Standards for Hospitals in effect
  • Leadership must create a culture of safety.
  • Implementation of patient safety programs.
  • Prevent errors through analysis and re-design of
    vulnerable systems.
  • Responsibility to disclose to patient/family if
    harmed by care provided.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
13
Error in Medicine
  • JCAHO National Patient Safety Goals
  • 2003 and 2004
  • Improve Patient Identification
  • Improve communication among caregivers
  • Improve Safety of high-alert medications
  • Eliminate wrong-site, wrong-patient,
    wrong-procedure surgery
  • Improve safety of Infusion Pumps
  • Improve clinical alarm systems
  • Reduce Healthcare acquired infections

New York Medical College Department of Family
Medicine
14
Medical Errors/Patient Safety
Literature
Articles on Medical Error/Patient Safety in
Refereed Journals by year of publication (as of
4/15/02).
New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
15
Medical Errors/Patient Safety
  • Medical Literature
  • Entire Issues devoted to the topic
  • - BMJ Feb 2000
  • Acad Emer Med November 2000
  • J Law Med Ethics Fall/Winter 2001
  • Academic Medicine October 2002

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
16
Medical Errors/Patient Safety Literature
  • Medical students and residents see errors made,
    make errors, do not see them discussed, and are
    greatly affected by medical errors.
  • Acculturation and moral development of medical
    students and residents starts early.
  • Future physicians need knowledge, skills and
    attitude to prevent and/or handle errors.
  • Residents can help identify and report errors.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
17
Medical Errors/Patient Safety
  • II. What is currently being taught and who is
    teaching it?
  • Published Literature on educating
  • students and residents.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
18
Medical Errors/Patient Safety Medical Schools
  • We found 4 curricula Literature on Predoctoral
    Medical Education described in published
    literature, 2 in the US.
  • We located brief references to unpublished
    curricula from 16 other schools.
  • Occurring in all years, mostly via
    lecture/discussion or panels many as part of the
    Medical Ethics or Introduction to Clinical
    Medicine courses.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
19
Medical Errors/Patient Safety Family Practice
Residencies
  • No published literature was found on educating
    about medical errors in Family Practice
    Residencies.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
20
Medical Errors/Patient Safety
  • Recommendations for Teaching
  • 5 Major Content Areas

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
21
Medical Errors/Patient Safety
  • Recommended Content Areas
  • 1. Epidemiology of medical error
  • (the Numbers)
  • Sources of the data.
  • Inpatient vs outpatient
  • Common types of error
  • High risk settings

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
22
Medical Errors/Patient Safety
  • Recommended Content Areas
  • 2. Ethical, Professional, Legal Issues
  • and the Culture of Medicine
  • Honestly as a core value
  • Obligations to patients
  • Threat of malpractice
  • Blame and shame culture
  • System errors vs bad apples

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
23
Medical Errors/Patient Safety
  • Recommended Content Areas
  • 3. How to respond to a Medical Error
  • Identity and remedy error
  • Report
  • Disclose
  • Document
  • Analyze
  • Heal

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
24
Medical Errors/Patient Safety
  • Recommended Content Areas
  • 4. Effects on the physician
  • (the second victim)
  • common reactions to making an error
  • coping mechanisms
  • need for support vs the current climate
  • importance of self-awareness

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
25
Medical Errors/Patient Safety
  • Recommended Content Areas
  • 5. Prevention of Medical Errors
  • Design of systems to prevent or absorb errors
  • Safety sciences especially Human Factors
    Engineering
  • Teamwork Training and Communication
  • Technology (e.g. CPOE)

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
26
Medical Errors/Patient Safety
  • Teaching Methods
  • Small group discussions to get at feelings about
    this topic
  • More effective with third year students than
    preclinical students.

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
27
Medical Errors/Patient Safety
  • Teaching Methods
  • Participation of faculty, residents, students in
    the Institutions Quality and Safety Meetings.
  • Role Modeling by Attendings of error reporting
    and disclosure
  • Simulations (e.g. use of standardized patient
    with whom an error must be discussed)
  • Work to increase discussion of medical error and
    patient safety in our specialty

28
Medical Errors/Patient Safety
  • Components of NYMC Curriculum
  • Didactic Session
  • Required Readings
  • Videotape/Feedback Session
  • Started in July 2000

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
29
Medical Errors/Patient Safety
  • Feedback and other Ideas

New York Medical College/Saint Josephs Medical
Center Department of Family Medicine
About PowerShow.com