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Medical Executive Committee

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Physician Basic Safety Training Note: This training is based on actual safety events that happened in UC Health facilities. This is not bureaucracy it matters! – PowerPoint PPT presentation

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Title: Medical Executive Committee


1
Physician Basic Safety Training
Note This training is based on actual safety
events that happened in UC Health facilities.
This is not bureaucracy it matters! There are
20 slides and it will take you 10 minutes to
complete please give safety a few minutes of
your time.
This course meets Hospital initial physician
training requirements for Blood Borne Pathogen
Training General Workplace Safety UC Medical
CenterAnnual Review (STAR) National Patient
Safety Goals
2
Confirm Identity When Writing Orders (National
Patient Safety Goal 1)
Case Report
A physician ordered amlodipine, atenolol, and
hctz for a patient. The nurse questioned the
orders, the doctor confirmed them, and a dose of
each was given. The doctor discovered later that
he had written these orders on the wrong patient.
  • Lesson Learned
  • Double-check patient identity when writing orders
    (CPOE, the EMR, and paper).
  • When someone expresses a concern, listen. And
    then take a moment to double-check they might
    be wrong but they might just be right also.

3
Keeping Verbal Orders Safe
Case Report
A physician gave a verbal order for 5 of
vercuronium during an emergent procedure. The
nurse thought she heard versed and gave that.
When the patient was not paralyzed, the doctor
said to give 5 more. After the second failed
dose, they realized the error and gave the
correct medication.
  • Lesson Learned
  • Try not to use verbal orders.
  • If a verbal order is needed, give a complete
    order.
  • Require the nurse to read back and verify what
    you said.
  • Confirm aloud that what you heard was correct.
  • Do this verbal back-and-forth deliberately every
    time.

4
Never Pre-Sign a Form Its Fraud
Case Report
This Discharge Summary form was found in a
patient's chart pre-dated and signed before it
was completed. Regulatory agencies consider this
to be falsification of records and a serious
offense. Dont do it!
5
Be Careful What Information Is Given to Visitors
and Relatives (HIPAA)
Case Report
A surgeon spoke to family members after a
procedure and told them off-hand that the
patients healing would be a little slower
because of his HIV. They had not been aware of
the patients HIV status previously.
  • Good privacy habits
  • Think about what you are disclosing and always
    ask visitors to step out of the room before
    discussing personal information. If the patient
    says it is OK for them to stay then youre OK.
  • Provide counseling in a private area whenever
    possible. If not possible, make attempts to
    protect privacy (e.g. pull the curtains and
    talk softly).

6
Medication Reconciliation Is a Physician
Responsibility
Case Report
An admitting physician listed a patients thyroid
dose as 25 mcg in his HP and that is what he
ordered for the patient. The patient's correct
home dose was 150 mcg. The patient had a tremor
and high thyroid tests on admission testing so
that the dose was reduced to 12.5 mcg and that is
what the patient was sent home on. He was
readmitted later with altered mental status and a
very low T4 and high TSH. Lessons
Learned Getting meds right when patients come in
and go home is really important and a physician
responsibility.
7
Checking and Reconciling Allergies Is Everyones
Responsibility
Case Report After checking office records and
asking the patient about allergies, a clinic
patient was given an IM dose of ceftriaxone. The
patient collapsed from anaphylaxis soon after.
Later, it was discovered that he had a previous
allergic reaction to ceftriaxone documented in
Last Word.
  • Lessons Learned Currently, UC Health has
    multiple data systems which means multiple lists
    of allergies. Cases like this one are one of the
    reasons we chose to buy an integrated electronic
    health record (EPIC).
  • It is important to check all available sources of
    allergy information before prescribing
    medications.

8
Key Things to Know About Heparin Protocols
  • There are 4 protocols for infusion heparin.
  • Using protocols reduces errors - use a protocol
    whenever possible.
  • Heparin dosing is weight-based up to a point. If
    a low-dose protocol patient weighs more than 83
    kg, use 83 kg rather than their true weight in
    the protocol.

9
Key Things to Know About Pain Management
  • Use a pain scale to assess the patient's
    perception of pain.
  • A behavioral scale is used for non-responsive
    patient.
  • Whenever an order is written for an IV titratible
    drip for sedation, the physician must indicate
    the target level of sedation.
  • If more than one pain medication is ordered for a
    patient, the physician must provide clear
    instructions on which medication is to be used
    first and when to go to the second med.

10
Use Restraints Sparingly Order and Document
Them Correctly When Used
  • It is a patient right to be free from restraints
    and seclusion unless needed to protect himself or
    others.
  • Less restrictive measures must be considered
    before ordering restraints.
  • All restraints require a physician order, initial
    assessment (why are the being used), and interval
    reassessment.

11
Fall Prevention (National Patient Safety Goal 9)
Case Report A patient returned from the PACU/OR
following surgery. The patient was oriented but
slightly confused from the anesthesia. The nurse
evaluated him but was called to care for a
patient having a seizure. Five minutes later, the
nurse was called back by the roommate saying the
patient was on the floor. The fall resulted in a
complication and return to surgery.
All patients are assessed for fall risk at
admission and during each shift as required by
our fall reduction program. At UCMC, Fall Risk
patients wear a yellow bracelet and will
be identified by a yellow or red magnet on the
door. At WCH, Fall Risk patients are identified
by a yellow magnet placed on the door.
12
Universal Protocol / Time Out
The challenge is not doing time outs, it's doing
them well. Pay Attention!
Case Report A patient had a left pleural
effusion. The physician tried a right
thoracentesis by mistake. The patient got a
pneumothorax. Records showed a checkmark in the
box on the procedure note indicating that the
team had done a time out.
Lesson Learned (1) Timeouts are a good safety
practice for anything you do that might hurt a
patient or is irreversible. (2) This is not about
a check mark in the box on the form. The
challenge is to be mindful and really pay
attention and check.
13
How to Report Safety Problems
  • Put an incident report into the computer system
    (On the main SharePoint page, click Enter an
    Incident Report and follow the prompts)
  • Patient Safety Hotline UC Medical Center
    584-2109
  • Anyone wishing to identify a potentially unsafe
    act,
  • process, procedure or system can call into the
  • hotline from any hospital phone line. This can be
  • used for reporting near misses, or when you are
  • unsure of the proper channel to report an
    incident.
  • Any report may be anonymous.

14
Better Documentation for Quality Remains a Key
Priority
Case Report Several years ago, UC Medical
Center(and its physicians) were rated as Worse
Than National Average for pneumonia mortality.
When we investigated this we found many
documentation and coding problems. A coding
improvement initiative was started and now UH is
back in the Same as National Average range.
Lessons Learned There are a lot of
organizations who are measuring and reporting
our quality on the internet using
publicly-available claims data and statistical
risk models. How our quality appears in such
models depends on how well we document what
patients really have.
15
Electronic Health Records Downtime
Case Report Our previous system went down on a
Sunday morning and stayed down for 14 hours. Some
staff were unaware of how to perform normal
functions without the computer and had trouble
getting lab and x-ray results.
As with any computer system, downtimes are a
reality. This can happen with EPIC too. Each unit
has a Downtime Packet with detailed plans on
what to do and a computer with running records of
key information such as patient medications. If a
downtime occurs, consult the Downtime Packet,
identify the downtime computer, and contact
radiology and the lab by phone for needed test
results.
16
Fire Safety in the Operating Room
Case Report A patient was undergoing surgery
and a decision was made to enter the chest
intraoperatively and Chloroprep (alcohol and
chlorhexidine) was applied to the skin by a
member of the surgical team. A Bovie was used to
cauterize bleeders. A fire occurred at the
incision and involved a lap sponge that was
extinguished on the floor. Every MD needs to
be aware of the flammability risks associated
with medical solutions, gases, surgical
materials, and electrocautery devices.
17
Fire Safety in the Operating Room
Fire can occur when an ignition source, oxidizer
and fuel are combined. These three elements
constitute the Fire Triangle and are abundant in
the Operating Room.
18
Reducing Blood-Borne Pathogen Exposures
Case Report A PCSA picked up a plastic bag to
dispose of it. Someone had placed bloody fluid in
the bag and a splash occurred into the PCSAs
eyes and mouth from a hole in the bag caused by
improperly disposed sharps. An OSHA inspection
followed and the hospital received an OSHA fine
of 26,500. Please dispose of blood and sharps
correctly.
Additional Advice Make sure you wear Personal
Protective Equipment (PPE) gloves, gowns,
masks, eye protection, surgical caps, hoods and
shoe covers where necessary. Place blood and
other infectious waste in Red biohazard
containers.
19
Lets Reduce Sharps Injuries
In 2012 there were 150 sharps-related injuries at
UCMC, and 17 sharps-related injuries at WCH. 65
of the injuries were to residents and fellows.
  • Here is what to do to reduce your risk of sharps
    injuries
  • Place sharps carefully in proper containers.
  • Do not overfill sharps disposal containers.
    Containers should be replaced when 3/4 full.
  • Be sure nothing sticks or spills out of the
    container.
  • Dispose of sharps disposal containers in
    bio-hazardous trash container, NOT in regular
    trash.
  • Clean reusable sharps carefully.
  • Put sharps away in their proper places.
  • Do not recap or bend needles.

20
Review and Test
  • Click Here to Take Test
  • REMEMBER, the most important question is your
    name!

Your browser will open up a new window for the
test. When you are finished, click the Done
button to submit.
21
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22
Logos/Guidelines
  • Do not stretch or smoosh the logos. If you need
    you resize, drag the image by the corner.
  • Leave a white space around the logo. No images or
    text should be touching or overlapping the logo.

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