Medical Staff's Role in Patient Safety

							Innovative Techniques for
Physicians to Improve Safety

Tammy Lundstrom, MD
Detroit Medical Center-Wayne State University
VP, Chief Quality and Safety Officer
Improving Patient Safety
means . . .

    Reducing medical errors.
   Reducing patient harm.
Patient Safety Terminology

      Structure        Process         Outcome

 Latent conditions    Active failure   Adverse event

     Root causes     Proximate cause    Sentinel event

         Blunt end      Sharp end       Patient

          Hazards       Failures       Harm
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


            Comprehensive Medical Safety Program


                  Medical Safety Committee
               Chair- Chief Medical Safety Officer


 Employee Safety         Patient Safety       Environmental Safety
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                   NEW

Who did it?           What happened?
Focus on bad event    Focus on Near Miss
  -Root Cause           -FMEA
Top down              Bottom up
Punish bad behavior   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.
AHA
  Develop an institutional policy or position statement
   on disclosure of unanticipated outcomes
  Differentiate between disclosure of an unanticipated
   outcome and an admission of liability
  Determine 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      Intended Meaning                  Misinterpretation                   Recommendation
Abbreviation



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


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


q.o.d. or      Every other day      Misinterpreted as qd or qid if the "o" is     Use every other day or q
Q.O.D.                              poorly written.                               48 hours and time/day to
                                                                                  begin therapy


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


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



AU             Both ears            Misinterpreted as "OU", "OS", and "OD".       Use both ears, left ear or
AS             Left ear                                                           right ear
AD             Right ear

OU             Both eyes            Misinterpreted as "AU", "AS', and "AD"        Use both eyes, left eye or
OS             Left eye                                                           right eye
OD             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 Sedation
Emergency Equipment
 Pharmacologic Antagonists and resuscitation
  drugs
 Intravenous access
 Supplemental oxygen
 Advanced airway equipment
 Cardiac defibrillator
Moderate Sedation
Discharge 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 Testing
Requirements
 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                Peer Review

  -Process                  -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