INSTITUTE FOR HEALTHCARE STUDIES FEINBERG SCHOOL OF MEDICINE Patient Safety in Ambulatory Care ECMH...

INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE

Patient Safety in Ambulatory Care

ECMH Grand RoundsFebruary 22, 2013

Donna Woods, EdM, PhD & Dan Evans, MD, MS

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ECMH Updates

• No Grand Rounds next month• Student surveys coming this weekend…• Next month each clinic will be receiving a QI

scorecard & will be asked to design at least 1 PDSA• Clinic attendance…• Follow ECMH on twitter https://

twitter.com/devans_at_NUmed• Or try our new webpage:• http://

www.feinberg.northwestern.edu/education/curriculum/learning-strategies/education-centered-medical-home/index.html

https://twitter.com/devans_at_NUmed



http://www.feinberg.northwestern.edu/education/curriculum/learning-strategies/education-centered-medical-home/index.html





Overview

• Definitions• Epidemiology of Risk in Ambulatory Care• Specific Areas of Focus• ECMH Patient Cases• ECMH Team Discussions of Approaches• Report Out and Discussion


• Patient safety: Freedom from accidental injuries.• Error: The failure of a planned action to be completed as intended (i.e.

error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning) (3). Errors may be errors of commission or omission, and usually reflect deficiencies in the systems of care.

• Adverse event: An injury related to medical management, in contrast to complications of disease (4). Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse events may be preventable or non-preventable.

• Preventable adverse event: An adverse event caused by an error or other type of systems or equipment failure (5).

• “Near-miss” or “close call”: Serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted.

• Hazard: Any threat to safety, e.g. unsafe practices, conduct, equipment, labels, names.

Definitions

4WHO Guidelines for Adverse Event Reporting and Learning Systems


Epidemiology1999

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Institute of Medicine Report

To Err is Human: Building a Safer Health System

44,000-96,000 preventable adverse events occur each year in the United States

5th leading cause of death Estimated costs of 38 – 50 million for

adverse events (4% of healthcare costs).


New Epidemiology

180,000 preventable adverse events occur each year in Medicare patients in the United States

13% of Medicare beneficiaries experienced at least one adverse event resulting in serious patient harm

5th 3rd leading cause of death

Estimated costs of 38 – 50 19.5 Billion for adverse events

2010

Department of Health and Human ServicesOffice of the Inspector General: Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, November 2010, OEI-06-09-00090. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf. Accessed January 5, 2012.

http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf


47% of People Concerned about Errors in Hospitals

7(Kaiser/AHRQ, 2000)


ECMH Cases

What safety issues have you seen in your clinics recently?

Student Presentations

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• Ambulatory events leading to hospital admission

• Events detected in electronic system• Malpractice claims• Collection of provider reports

Studying Ambulatory Adverse Events

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Adverse Events in Ambulatory Care Settings

• Based on the Conservative IOM Data

• Ambulatory events leading to hospital admission– ~171,000 discharges annually

in the US related to ambulatory care adverse events

– ~76,000 discharges annually related to ambulatory care preventable adverse events

Woods et. al., QSHC, 2007


Ambulatory Care Preventable Adverse Event Types

• Preventable Adverse Events– Diagnostic – Surgical

• Harm– Surgical (X = 4.0)– Diagnostic (X = 3.4)– No significant difference

among the others

0102030405060

Preventable Adverse EventsEvent Type


Ambulatory CarePreventable Adverse Events

• Most common setting of Preventable Adverse Events – Physician’s Office– ED– Home

• Mean Harm– Highest in Ambulatory Surgery – Diagnostic

0102030405060

Preventable Adverse EventsAmbulatory Care Setting Type


Ambulatory Care Preventable Adverse Events

• Preventable Adverse Events– Primary Care– Emergency Medicine, Medical,

and Surgical Specialties

• Harm– Primary Care (X = 4.0)– Emergency Medicine, Surgical

and Medical Specialties (X = 2.5 – 3.0)

0102030405060

Preventable Adverse EventsAmbulatory Care Provider Type

INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINEGandhi, T. K. et. al. Ann Intern Med 2006;145:488-496

Breakdown Points in the Diagnostic Process in Ambulatory Care


Communication

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Frequency of Lab Testing Errors

Error Category Physician

Ordering the test 15%

Implementing the test 20%

Reporting results to the clinician

28%

Clinician responding to the results

5%

Patient notification 6%

Administration 15%

Other process errors 5%

243 physicians reported 639 reports with 1010 errors

Dovey SM, Meyers DS, Phillips RL Jr., et. al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002 Sep;11(3):233-8


Outpatient Medication Safety

• In a seminal study of 24 outpatient practices– 1879 prescriptions from 1202 patients– Outpatient medication errors in 27 of 100

patients – 62 (3% of all prescriptions) had potential

for patient injury (potential ADEs); – 1 was potentially life-threatening (2%) and

15 were serious (24%). – Errors in frequency (n=77, 54%)and dose

(n=26, 18%) were common. – Advanced checks (including dose and

frequency checking) could have prevented 95% of potential ADEs.

Ghandi TK, Weingart S, Seger AC, et. al. Outpatient Prescribing Errors and the Impact of Computerized Prescribing. Journal of General Internal Medicine, 2005; Volume 20, Issue 9, Pages 837-841


Adverse Drug Events in

Ambulatory Care• The rate of outpatient ADEs

may be ~4 X as high as that reported in hospital studies and

• More than one third of these events are preventable

• Number of medications significantly associated with adverse events

Gandhi et. al. 2003

http://content.nejm.org.ezproxy.galter.northwestern.edu/content/vol348/issue16/images/large/08t3.jpeg


Ambulatory Care Medication Adverse Events

• Forty (70%) of the preventable ADEs were related to parent drug administration.

• Improved communication between health care providers and parents and improved communication between pharmacists and parents, whether in the office or in the pharmacy, were judged to be the prevention strategies with greatest potential.

19Kaushal, et. al., 2007

http://content.nejm.org.ezproxy.galter.northwestern.edu/content/vol348/issue16/images/large/08t3.jpeg


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ASIPS Study:Frequency of Errors


Administrative 34%

Lab testing and imaging 25%

Medications and treatment

23%

Problems related to both Medications and diagnostics

14%

475 physicians submitted 608 reports

Fernald DH, Pace WD, Harris DM, West DR, Main DS, Westfall JM. Event reporting to a primary care patient safety reporting system: A report from the ASIPS Collaborative. Ann Fam Med. 2004 Jul-Aug;2(4):327-32


AAFP National Research Network Error Reports


Administrative 34%

Lab testing and imaging 25%

Medications and treatment 23%

Error in the execution of a clinical task

6%

Wrong diagnosis 4%

Wrong treatment for diagnosis 4%

42 physicians made 344 reports

Dovey SM, Meyers DS, Phillips RL Jr., et. al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002 Sep;11(3):233-8


Australia Error Reports

Error Categories Proportion

Medication issues 54%

Treatment issues 43%

Delayed or missed diagnosis 34%

Bhasale AL, Miller GC, Reid SE, Britt HC. Analyzing Potential Harm in Australian General Practice: An Incident-Monitoring Study. Med J of Australia 1998;169:73-76.

324 GPs reported 805 incidents in 1993-1995


Ambulatory Adverse Events

• Diagnostic errors: Most frequent and most harmful Range from trivial failures (overlooking a minor lab

abnormality) to more serious errors (switching of specimens between two patients)

Seven stages in the diagnostic process, with potential for error at each stage: Access and presentation; history taking; physical

examination; testing; assessment; referral; and follow-up

• Communication errors: Hospital discharge communication Research on follow-up of tests pending at discharge Discontinuity of care at care transitions Communication of test results Communication and non-adherence Between-team communication

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• Medication safety: Drugs widely used, with narrow therapeutic

ranges and high toxicities associated with ADEs and/or medication errors

Elderly, taking many medications, comorbidities

Medication reconciliation


How do we achieve safety in health care?

• Safe Culture• Safe Systems• Safe People• Error (event) reporting, surveillance, and

other data gathering methods inform improvement

• Improvement Methods


High Reliability Organizational Principles of Safe Culture

• Preoccupation with failure • Reluctance to simplify• Sensitivity to operations • Commitment to resilience • Deference to expertise

Continuous Learning and Improvement


Changing the Paradigm“Everything’s Fine”

Out InAll is fine Endless opportunities

for improvementErrors are rare Errors everywhereTell as little as you can Tell whatever you canKeep Board out Actively involve LeadershipMDs don’t participate Docs actively involvedOur error rate is average No threshold for errors


• C Concerned

• U Uncomfortable

• S Safety Issue

CUS

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ECMH Cases:

What safety issues have you seen in your clinics recently?

Student Presentations

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• ECMH Teams Meet to discuss challenges in your ECMH home

• How common are medical errors?• What is the proper student response when confronted with a medical

error about to happen?• What is the proper student response when confronted with a medical

error that has already occurred?– Should the student report it?– How ?– When?– To whom? – Is there a support number or contact for students to call?

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• You’re an M4 student and you are excited that Epic allows you to write medication orders – you write a new script for glyburide for your 85 yo diabetic and you realize the next week that you had accidently doubled the dose and your attending signed your script without catching the error…

• Reportable? How? When? To whom? What if you just asked your for a letter of rec?

Hypothetical scenarios:

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• You’re an M3 student . You are following your patient’s progress remotely. Last week your patient needed a script for his tuberculosis meds called into the pharmacy. You had asked your attending to e-Rx the meds, and you reminded him again at the end of clinic huddle. One week later there’s no script…

• Reportable? How? When? To whom? Do you feel comfortable calling your preceptor?

Hypothetical scenario:

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• You’re an M2 student . You go visit your 84 yo patient in the hospital who was admitted 3 days ago for failure to thrive. You find she has a foley catheter (not indicated), her med list was changed (ambien & benedryl were added) and the team is ordering a CT scan to look for PE (but her GFR is 30). You have some safety concerns…

• Reportable? How? When? To whom? Are you comfortable voicing concerns to hospitalist?

Hypothetical scenario:

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Discussion& Wrap-up

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INSTITUTE FOR HEALTHCARE STUDIES FEINBERG SCHOOL OF MEDICINE Patient Safety in Ambulatory Care ECMH...

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