Innovative Techniques for Physicians to Improve Safety

Tammy Lundstrom, MDDetroit Medical Center-Wayne State University

VP, Chief Quality and Safety Officer

Improving Patient Safetymeans . . .

Reducing medical errors.

Reducing patient harm.

Patient Safety Terminology

Structure Process Outcome

Root causes Proximate cause Sentinel event

Blunt end Sharp end Patient

Hazards Failures Harm

Latent conditions Active failure Adverse event

Overview of a Comprehensive Program

Detroit Medical Center

13,000 employees 3000 physicians 1000 Graduate Medical Residents 1000 Medical Students Nursing Students Pharmacy Students PA Students

Demonstration of Leadership Support Name of System Quality Council changed

to System Quality-Medical Safety Council Chief Medical Safety Officer named Medical Safety Committee Established Monthly reports to the Board Medical Safety Plan Developed

Value of a Comprehensive Program Reduce fear of reporting errors/near

misses, gather more data Reduce errors through tracking,

trending,analysis, and targeted improvement projects

Reduce errors through prevention

Comprehensive Program

C om p reh en s ive M ed ica l S a fe ty P rog ram

E m p loyee S afe ty P atien t S a fe ty E n viron m en ta l S a fe ty

M ed ica l S a fe ty C om m itteeC h a ir- C h ie f M ed ica l S a fe ty O ffice r

First Steps

Common definitions agreed upon Common database to enter events Information flows through each site

Leadership and Performance Improvement Committee

Information flows from site to system Critical aspects of safety agreed upon

What is a Safety Culture

And how is it achieved?

Lessons from a Leader

“Safety is not a priority, it’s a way of life”

Paul O’Neill

CEO Alcoa Steel

Treasury Secretary

Safety Culture Involves Paradigm Shift

OLD

Who did it?

Focus on bad event

-Root Cause

Top down

Punish bad behavior

NEW

What happened?

Focus on Near Miss

-FMEA

Bottom up

Fix broken processes

Advantage to Focus on near Misses No patient harm, therefore no blame No guilt Focus on prevention No fear of litigation

Disclosure of Unanticipated Outcomes to Patients and Families

What is an Unanticipated Outcome?

A negative or unexpected result stemming from– A diagnostic test, medical judgment or

treatment, surgical intervention, or (commission)

– The failure to perform a necessary test, treatment , or intervention (omission)

Why Disclosure?

We are our patient’s advocates Literature shows that after an unanticipated

outcome, the patient and family want to know honestly what happened, and how the hospital is going to prevent future events

Rebuilds trust Caregiver/Doctor relationship

Advocating Disclosure

American Society for Healthcare Risk Managers

JCAHO AHA AMA

JCAHO

Standard

RI.1.2.2 Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.

AHADevelop an institutional policy or position

statement on disclosure of unanticipated outcomesDifferentiate between disclosure of an unanticipated

outcome and an admission of liabilityDetermine who will be responsible for informing

the patient, and, where appropriate, the family and/or legal representative, about the unanticipated outcome.

Educate caregivers and staff about your organization’s policies and procedures covering this issue, and consider communications training for those charged with disclosing unanticipated outcomes

Specify documentation requirements regarding disclosure

ASHRM

Each Healthcare institution must develop it’s own policy on management of unanticipated outcomes

Disclosure of such information to patients and families must reflect the requirements of applicable law

Differentiate between unanticipated outcome and admission of liability

For additional detail on implementation of a policy on disclosure of outcomes, consistent with the requirements of this standard:

AMA

AMA Professional Code of Ethics

Steps to Follow After Event

Care for immediate needs of patient Preserve evidence (Medical equipment) Document in the medical record Report (Risk Management) Disclose

Documentation

Document only the facts of what occurred and treatment rendered

NOT– Blame– Subjective feelings, opinions– Speculation– Reference to “Incident report”

Incident Report

Complete and submit Notify Risk Management FDA notification if Medical Device or

Medication Begin Root Cause/Intensive analysis to

examine process changes that may prevent future events

Who Will Inform the patient?

The attending physician May need pre-disclosure conference with

Nursing, Risk Management All patient questions should be referred to

the attending physician

When Should Disclosure Occur?

As soon as possible after immediate needs of patient addressed

Gather facts FIRST May not have all the facts yet, in which

case DON’T SPECULATE! Offer to speak again as facts become known

How?

Convey compassion– “I am sorry for your…..” “I am sorry that you…”

Known facts Privacy No BLAME on any member of healthcare team Avoid defensive posture/reaction Respond to patient complaints (provide forms,

contact patient advocates/ombudsman)

Health Care Worker Involved in Error AVOID BLAME Provide counseling, if needed

Remember: No one goes to work intending to make a mistake

HCW feel tremendous guilt after event that harms patient

Examples from the Front Lines

Physician Leadership is Key

Medication Safety

Why physicians?

Medication Safety

Large % medication errors due to prescribing (20-49%)

For the most part- physicians prescribe DMC Medication Safety Committee

– Physician Chair– Review all events– Review ISMP alerts/External incidents– Chemotherapy Administration Policy

Medication Safety- Physician Lead PI Look-alike Sound-alike Posters and alerts Define safe medication order writing

policy/pocket card Promote physician incident entry Develop delineation of privileges form

related to chemotherapy administration

Dangerous Abbreviation

Intended Meaning Misinterpretation Recommendation

U Units Mistaken as a zero or a four when poorly written, resulting in overdose. (4U seen as "40" or 4U seen as "44")

Use units

g Micrograms Mistaken for "mg" when handwritten, resulting in overdose

Use mcg

q.o.d. or Q.O.D.

Every other day Misinterpreted as qd or qid if the "o" is poorly written.

Use every other day or q 48 hours and time/day to begin therapy

TIW Three times a week Misinterpreted as "three times a day" or "twice a week"

Use three times a week

cc Cubic centimeters Misread as "u" (units) Use mL

AUASAD

Both earsLeft earRight ear

Misinterpreted as "OU", "OS", and "OD". Use both ears, left ear or right ear

OUOSOD

Both eyesLeft eyeRight eye

Misinterpreted as "AU", "AS', and "AD" Use both eyes, left eye or right eye

Physician Education

Physician Led

Board Support All physicians and trainees will have 3 hours of

mandated compliance and safety education each credentialing cycle

Failure to complete required education will be deemed voluntary resignation

Web-based Continuing Medical Education credits Required for all new applications to the Medical

Staff Physician experts develop and approve education

modules

Physician Education Modules

Sexual Harassment Code of Conduct Pain Management Medical Safety and Incident Reporting Restraint Use Conscious Sedation Infection Control Life Safety

Moderate Sedation

for Physicians and

Licensed Independent Practitioners

Moderate Sedation

Moderate sedation/analgesia describes a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Moderate Sedation Patient Evaluation Standards History and Physical includes:

– abnormalities of major organ systems with specific focus on the cardiopulmonary history

– pregnancy status

– previous adverse experiences with sedation/analgesia, as well as anesthetic techniques

– current medications and drug allergies/adverse reactions

– time and nature of last oral intake of foods, fluids, etc.

– history of tobacco, alcohol, or substance use or abuse

Moderate Sedation Patient Evaluation Standards Focused physical exam that minimally includes an

evaluation of the airway and auscultation of the heart and lungs.

Assignment of ASA Classification of Physical Status Pre-procedure laboratory and diagnositic testing guided by

the patient’s underlying medical condition. History and physical examination are valid up to 30 days

prior to the scheduled procedure. Verification and review of this information is necessary immediately prior to the provision of moderate sedation.

Moderate Sedation Monitoring Standards

Level of consciousness– Monitoring the patient’s response to verbal and/or tactile stimuli

should be routine (unless contraindicated by procedure). Pulmonary Ventilation

– Ventilatory function is continually monitored by observation and/or auscultation during the procedure.

Oxygenation– Continuously monitored by pulse oximetry with appropriate low

limit alarms. Hemodynamics

– Baseline blood pressure established; measured at regular intervals intra and post-procedure. Electrocardiograph continuously monitored.

Moderate SedationEmergency Equipment Pharmacologic Antagonists and resuscitation

drugs Intravenous access Supplemental oxygen Advanced airway equipment Cardiac defibrillator

Moderate SedationDischarge Criteria Following the provision of moderate sedation, patients are

monitored until they are suitable for discharge:– Level of consciousness and hemodynamic/respiratory variables

evaluated and no longer at risk for sedation and cardiorespiratory depression.

– For patients who received pharmacologic antagonists, post-procedure monitoring should continue for a sufficient period of time to detect and appropriately treat its recurrence.

Discharge criteria that pertain to the patient population and specific procedures is developed:– A qualified physician or registered nurse should be in attendance

until discharge criteria are fulfilled.

Sharps Safety

Why Physicians?

Physician-Performed TestingRequirements Dfn: Test personally performed by a

physician in conjunction with the physical examination or treatment of a patient

PPT

Amniotic fluid pH Cervical mucous smears for ferning Fecal leukocytes Gastric biopsy urease Nasal smears for eosinophilia Occult blood, fecal and gastric Pinworm exam

PPT

Post-coital mucous exam Potassium hydroxide preparations Semen analysis, qualitative Synovial fluid for crystals Urine dipstick Urine sediment microscopy Vaginal wet mount microscopy

What’s required?

Policy- scope of testing for physicians Procedure manual- specimen handling QI program

– Quality control, reagents

– Instrument maintenance

– Corrective action equipment/reagent failure

Documented training- test specific Competency assessment-credentialing System for reporting results

How will you comply?

Training and documentation Reagent control

– No bottles in pockets!!

House staff? Other trainees?

Sharps Safety

Physicians perform many procedures– Forgotten “frontline worker”

Physician sharps injuries under-reported HIV conversions

– 57 documented conversions

– 6 physicians

Many Safety devices used primarily by physicians– Safety Scalpels

– Blunted suture needles

Physician Peer review and Patient Safety

Incident Reports

Incident Occurs

Root Cause

-Process

Peer Review

-Physician specific practice as it relates to care of this patient

Goal of Peer Review

Monitor and improve physician care of patients

Accomplish by:– Open, non-punitive discussion – Review and discuss alternatives– Disseminate to ALL physicians

Monthly Vignettes

Code Blue

Get away from “monitoring Code” Move towards: review previous 48 hour

record– Could this event have been prevented?– Were signs of deterioration missed?

• Elevated BP, dropping BP

• Elevated HR, dropping HR

• Elevated RR