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Issues in Medical Errors Report to the Wyoming Health Care center doc


Issues+in+Medical+Errors%0d%0aReport+to+the+Wyoming+Health+Care+Commission+August+14%2c+2006%0d%0a%0d%0aFran+Cadez%2c+J.D.%2c+M.B.A.%0d%0a%0d%0a%0cMedical+Errors+and+Patient+Safety%0d%0a%ef%81%b5+Medical%0d%0a%0d%0aerrors+are+a+problem+of+epidemic+proportions%0d%0a%e2%80%93+44%2c000+to+98%2c000+hospitalized+patients+die+per+year+%e2%80%93+%2417-29+billion+costs+from+preventable+errors+%e2%80%93+Average+increased+cost+of+medication+error+%3d+%244%2c700+per+admission%0d%0a%e2%80%93+Rosenthal%3a+National+Academy+for+State+Health+Policy%0d%0a%0d%0a%0cIOM+Recommendations%0d%0afocus+on+patient+safety+%ef%81%b5+Identify+and+learn+from+errors+%ef%81%b5+Set+performance+standards+and+expectations+for+safety+%ef%81%b5+Implement+safety+systems+within+health+care+organizations.%0d%0a%ef%81%b5+National%0d%0a%0d%0a%0cIdentify+and+Learn+from+Errors%3a+Reporting+Systems%0d%0a%ef%81%b5+25%0d%0a%0d%0astates+have+authorized+adverse+event+reporting+programs+(as+of+Dec.+2005)%0d%0a%e2%80%93+Accountability%3a+Identify+system+weaknesses+and+undertake+corrective+actions+%e2%80%93+Facility+education%3a+Identify+trends+and+best+practices%3b+lessons+learned%0d%0a%0d%0a%0cWyoming+Medical+Errors+Study+2005%0d%0aA.+B.+C.+D.+D.+E.+F.+Defining+Medical+Errors+Detecting+Medical+Errors+Issues+in+Reporting+Medical+Errors+W.S.%c2%a7+35-2-912+National+Patient+Safety+Initiatives+Prevention+Efforts+Compensation+Systems+for+Medical+Injury%0d%0a%0d%0a%0cW.S.+%c2%a735-2-912+(2005)%0d%0asystem+%ef%81%b5+Licensed+healthcare+facilities+report+to+WDH+%ef%81%b5+Requires+Patient+Safety+Officer+to+submit+report+%ef%81%b5+Facility+identified+but+not+reporting+individual%0d%0a%ef%81%b5+Mandatory%0d%0a%0d%0a%0cW.S.+%c2%a735-2-912+(2005)+What+is+reported%3f%0d%0a%ef%81%b5+Events%0d%0a%0d%0acausing+serious+injury%2c+death+or+risk+thereof+NQF%e2%80%99s+List+of+Serious+Reportable+Events%0d%0a%0d%0a%ef%81%b5+Adopts%0d%0a%0d%0a%e2%80%a2+Will+allow+comparisons+with+national+data%0d%0a%0d%0a%0cW.S.+%c2%a735-2-912+(2005)+How+is+the+data+used%3f%0d%0a%ef%81%b5+WDH%3a%0d%0a%0d%0a%e2%80%a2Will+provide+annual+reports+of+aggregate+data+%e2%80%a2May+hire+experts+to+interpret+data+%ef%81%b5+Data+not+shared+with+health+care+licensing+boards+%ef%81%b5+Protections+from+discovery+and+suit%0d%0a%0d%0a%0cPreliminary+Data%0d%0afrom+just+a+few+hospitals+%ef%81%b5+Many+questions+about+what+to+report+%ef%81%b5+Many+facilities+have+not+designated+a+Patient+Safety+Officer+%ef%81%b5+Interest+in+reporting+electronically%0d%0a%ef%81%b5+Reports%0d%0a%0d%0a%0cChallenges%0d%0a%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+%e2%80%a2+No+incentives+to+report+No+sanctions+for+failure+to+report+No+standard+definitions+or+classification+system+No+data+shared+with+health+care+licensing+boards+No+corrective+action+plan+required+No+sharing+of+%e2%80%9clessons+learned%e2%80%9d+or+best+practices+No+provision+to+consider+latest+research+in+adverse+event+reporting+No+electronic+reporting+No+provision+for+on-going+evaluation+of+reporting+system%0d%0a%0d%0a%0cDoes+reporting+errors+improve+patient+safety%3f%0d%0a%ef%81%b5+%ef%81%b5%0d%0a%0d%0a%ef%81%b5%0d%0a%0d%0a%ef%81%b5%0d%0a%0d%0aOpportunities+for+improvement+Facilities+can+measure+effectiveness+of+system+changes+over+time+Sharing+data+on+multiple+levels+can+lead+to+system+wide+change+Since+there+is+no+way+to+assure+complete+reporting%2c+we+can%e2%80%99t+measure+whether+changes+in+reporting+rates+are+due+to+improved+care.%0d%0a%0d%0a%0cRefining+the+Reporting+Process%0d%0a1.+2.+3.+4.+5.+6.%0d%0a%0d%0aStandardize+reporting+and+classification+of+errors+Training+on+reporting+events%2c+conducting+analysis%2c+action+plans+Review+aggregate+data+Allow+for+meaningful+changes%2fimprovement+Feedback+to+reporting+facilities+Electronic+reporting%0d%0a%0d%0a%0cThe+only+real+mistake+is+the+one+from+which+we+learn+nothing.%0d%0a%0d%0aJohn+Powell%0d%0a%0d%0a%0cFederal+Patient+Safety+and+Quality+Improvement+Act+(2005)+into+law+July%2c+2005+%ef%81%b5+Legal+privilege+and+confidentiality+protections+%ef%81%b5+Creates+network+of+databases+%ef%81%b5+National+reporting+standards+%ef%81%b5+State+must+apply%2c+WY+may+not+qualify+%ef%81%b5+No+provider+accountability%0d%0a%ef%81%b5+Signed%0d%0a%0d%0a%0cAmbulatory+Care%0d%0asettings+perform+%c2%be+of+all+medical+procedures+%ef%81%b5+More+logistically+complicated%2c+more+players+%ef%81%b5+Handoffs+and+transitions+%ef%81%b5+Failure+to+diagnose+is+fastest+growing+area+of+malpractice%0d%0a%e2%80%93+25%25+involve+follow-up+system+failures%0d%0a%ef%81%b5+Level+%ef%81%b5+Ambulatory%0d%0a%0d%0aof+safety+awareness+unknown%0d%0a%0d%0a%0cPhysician+Practice+Patient+Safety+Assessment%0d%0a%ef%81%b5%0d%0a%0d%0aEvaluates+safe+practices+in+six+domains%3a%0d%0a1.+Medications+2.+Handoffs+and+Transitions+3.+Surgery%2c+anesthesia%2c+sedation+and+invasive+procedures+4.+Personnel+qualifications+5.+Practice+management+and+culture+6.+Patient+education+and+communication%0d%0aMedical+Group+Management+Association%2c+2005%0d%0a%0d%0a%0cEstablish+Assessment+Goals%0d%0aawareness+of+patient+safety+%ef%81%b5+Establish+a+baseline+of+patient+safety+practices+%ef%81%b5+Premium+reduction+for+survey+completion+%ef%81%b5+Use+assessment+data+to+facilitate+behavior+change%0d%0a%ef%81%b5+Increase%0d%0a%0d%0a%0cIT+in+Ambulatory+Care%0d%0a%ef%81%b5%0d%0a%0d%0aIT+can+improve%0d%0a%e2%80%93+%e2%80%93+%e2%80%93+%e2%80%93+%e2%80%93+%e2%80%93%0d%0a%0d%0amedication+safety+test+result+follow-up+transitions+in+care+team+work+communication+decision+support%0d%0a%0d%0a%ef%81%b5%0d%0a%0d%0aIT+Implementation+requires%0d%0a%0d%0a%e2%80%93+strong+support+of+health+care+leaders+%e2%80%93+pacing+%e2%80%93+on-going+training%0d%0a%0d%0a%0cIT+Adoption%0d%0a%ef%81%b5+Slow%0d%0a%0d%0a%ef%81%b5+Complex%0d%0a%0d%0arequires+changing+established+workflow+patterns+%ef%81%b5+Costly+%ef%81%b5+Suffers+from+lack+of+standardization%0d%0a%0d%0a%ef%81%b5+Disruptive%2c%0d%0a%0d%0a%0cPREVENTION%0d%0aapproaches+%ef%81%b5+Leadership+and+Teamwork+%ef%81%b5+Assessing+Risk+and+Implementing+Change+%ef%81%b5+Education+and+Training+%ef%81%b5+Patient+Safety+Regulatory+Issues+%ef%81%b5+Costs+of+Prevention%0d%0a%ef%81%b5+National%0d%0a%0d%0a%0cVA+National+Center+for+Patient+Safety+and+Kaiser+Permanente%0d%0a%ef%81%b5+GOAL%3a%0d%0a%0d%0aTo+develop+a+safety+culture+that+promotes+continual+innovation+and+improvement+and+which+transcends+whatever+particular+safety+methodology+is+used.%0d%0a%ef%81%b5+Organizational%0d%0a%0d%0acritical%0d%0a%0d%0aculture+change+is%0d%0a%0d%0a%0cVA+National+Center+for+Patient+Safety%0d%0asystems+for+vulnerability+%ef%81%b5+Nonpunitive+approach+to+encourage+reporting+%ef%81%b5+Computer-aided+analysis+of+errors+%ef%81%b5+Action+plans%2c+implementation+and+follow-up%0d%0a%ef%81%b5+Reviewing%0d%0a%0d%0a%0cKaiser+Permanente%0d%0athe+stage+through+%e2%80%9cteam+leadership%e2%80%9d+%ef%81%b5+Corps+of+structured+communication+techniques+for+critical+interactions+(SBAR)%3a%0d%0a%e2%80%93+Situation+%e2%80%93+Background+%e2%80%93+Assessment+%e2%80%93+Recommendation%0d%0a%ef%81%b5+Setting%0d%0a%0d%0a%0cKaiser+Permanente%0d%0a%ef%81%b5+Common%0d%0a%0d%0aunderstanding+of+situation+to+eliminate+%e2%80%9csurprises%e2%80%9d+Bridge+cognitive+gaps+and+unjustified+assumptions+about+team+member%e2%80%99s+knowledge%0d%0a%0d%0a%ef%81%b5+Briefings%3a%0d%0a%0d%0a%ef%81%b5+Debriefings%0d%0a%0d%0afollowing+procedures%0d%0a%0d%0a%0cTypes+of+Compensation+Systems+for+Medical+Injury%0d%0a%ef%81%b5+Tort%0d%0a%0d%0astandard%2c+trial+process%2c+but+replace+juries+with+expert+judges+standard%2c+but+replace+trial+with+mandatory+arbitration+tort+standard+and+trial+process+with+Administrative+Compensation+System+(ACS)%0d%0a%0d%0a%ef%81%b5+Tort%0d%0a%0d%0a%ef%81%b5+Replace%0d%0a%0d%0a%0cAre+frivolous+medical+malpractice+claims+prevalent+in+the+tort+system%3f%0d%0a%ef%81%b5%0d%0a%0d%0aStudy+of+1400+closed+malpractice+claims+from+five+different+liability+insurers+across+the+country.+(May%2c+2006)%0d%0a%e2%80%93+In+3%25+no+medical+injury+identified+%e2%80%93+37%25+of+claims+did+not+involve+medical+error+BUT+most+of+these+did+not+result+in+compensation%0d%0a%0d%0a%ef%81%b5%0d%0a%0d%0aConclusion%3a+Tort+system+does+a+decent+job+of+excluding+meritless+claims.%0d%0a%0d%0a%0cHowever+.+.+.%0d%0ain+six+claims+(16%25)+involved+medical+error+but+received+no+payment+%ef%81%b5+Total+cost+of+litigation%2c+including+defense+costs+and+contingency+fees+consumed+54%25+of+compensation+paid+to+plaintiffs.+%ef%81%b5+Time+between+injury+and+resolution+averaged+five+years%0d%0a%ef%81%b5+One%0d%0a%0d%0a%0cGradations+of+Covered+Injury+Options%0d%0aAll+medical+injuries+Adverse+events+Preventable+adverse+Events+Negligent+Injuries+Increasing+number+of+medical+injuries+qualifying+for+compensation%0d%0a%0d%0aIncreasing+restrictiveness+of+compensation+test%0d%0a%0d%0aStuddert%2c+D%2c+Health+Courts%3a+What+are+They+and+Why+do+We+Need+Them%3f+Presentation+at+the+Brookings+Institution%2c+June%2c+2005%0d%0a%0d%0a%0cACS%3a+Characteristics%0d%0a1.+Outside+the+regular+tort+system+2.+Decisions+based+on+consistent+valuations+3.+Standard+of+care+broader+than+negligence%2c+but+not+strict+liability+4.+Decisions+made+on+evidence-based+criteria+5.+Guidelines+for+compensating+both+economic+and+non-economic+loss+6.+System+incentivizes%2c+reinforces+and+empowers+improvements+in+patient+safety%0d%0a%0d%0a%0cACS%3a+Design+Considerations%0d%0a%ef%81%b5+Jurisdiction%0d%0a%0d%0amakers+%ef%81%b5+Access+for+Claimants+%ef%81%b5+Compensation+Standard+%ef%81%b5+Damages+guidelines+%ef%81%b5+Financing+the+system+%ef%81%b5+Relationship+to+patient+safety+structures%0d%0a%0d%0a%ef%81%b5+Decision%0d%0a%0d%0a%0cCollateral+Effects%0d%0a%ef%81%b5+Less%0d%0a%0d%0adefensive+medicine%3f%0d%0a%0d%0a%e2%80%93+In+an+experience-rated+system%2c+still+some+incentive%0d%0a%ef%81%b5+Healthier%0d%0a%0d%0aphysician-patient%0d%0a%0d%0arelationships%3f%0d%0a%ef%81%b5+Less%0d%0a%0d%0apunitive+environment+for+patient+safety+initiatives%3f%0d%0a%0d%0a%0cACS+Systems%0d%0aBirth-Related+Neurological+Injury+Compensation+Act+(NICA)+%ef%81%b5+Virginia%e2%80%99s+birth+injury+compensation+system+%ef%81%b5+Sweden%2c+Denmark%2c+Finland%2c+Norway%2c+Iceland+%ef%81%b5+New+Zealand%0d%0a%ef%81%b5+Florida%0d%0a%0d%0a%0cFair+and+Reliable+Medical+Justice+Act%0d%0a%ef%81%b5+Senators%0d%0a%0d%0asponsors%0d%0a%0d%0aMike+Enzi+and+Max+Baucus%2c%0d%0a%0d%0a%ef%81%b5+Planning%0d%0a%ef%81%b5+Early%0d%0a%0d%0aand+Demonstration+Grants%0d%0a%0d%0aDisclosure+and+Compensation+%ef%81%b5+Administrative+Determination+of+Compensation+%ef%81%b5+Special+Health+Court%0d%0a%0d%0a%0cMedical+Error+Disclosure+and+Compensation+Act+(MEDiC)%0d%0a%ef%81%b5+Senators%0d%0a%0d%0asponsors+%ef%81%b5+Grants+and+technical+support%3a%0d%0a%e2%80%93+Disclosure+of+medical+errors+to+patients+%e2%80%93+Offer+of+fair+compensation+%e2%80%93+Negotiations%2c+apology+confidential%2finadmissible%0d%0a%ef%81%b5+Reduced%0d%0a%0d%0aClinton+and+Obama%2c%0d%0a%0d%0acosts+applied+to+premiums%2c+patient+safety+initiatives.%0d%0a%0d%0a%0cMEDiC%0d%0a%ef%81%b5+Create%0d%0a%0d%0aOffice+of+Patient+Safety+and+Health+Care+Quality%3a%0d%0a%e2%80%93+Study+performance%2c+systems+standards%2c+best+practices+%e2%80%93+Analysis+of+medical+liability+insurance+market+%e2%80%93+Create+database+of+unsuccessful+negotiations+to+determine+reasons%2c+trends+and+effects%0d%0a%0d%0a%0cEarly+Offers%0d%0a%ef%81%b5+Illinois%0d%0a%0d%0aadopts+Sorry+Works!%0d%0a%0d%0a%e2%80%93+Promptly+acknowledge%2c+apologize+and+offer+fair+settlement+%e2%80%93+Patients+encouraged+to+retain+counsel+%e2%80%93+Grant+covers+costs+exceeding+malpractice+average%0d%0a%ef%81%b5+DHHS%0d%0a%0d%0aEarly+Offers+Pilot+Program%0d%0a%0d%0a%e2%80%93+Early+offers+for+malpractice+claims+asserted+under+FTCA%0d%0a%0d%0a%0cTransparency%0d%0a%e2%80%a2+Patients+want%3a%0d%0a%ef%81%b5+Apology%0d%0a%ef%81%b5+To%0d%0a%0d%0aknow+cause%2c+consequences+and+future+prevention+of+errors+%ef%81%b5+Why+error+occurred%0d%0a%0d%0a%e2%80%a2+Physicians%3a%0d%0ato+apologize%2c+but+%ef%81%b5+Fear+litigation+%ef%81%b5+Uncertain+about+what+actually+happened%0d%0a%ef%81%b5+Want%0d%0a%0d%0a%0cNEXT+STEPS%0d%0a%0d%0a%0cRefining+the+Reporting+Process%0d%0a1.+2.+3.%0d%0a%0d%0a4.%0d%0a5.+6.%0d%0a%0d%0aStandardize+reporting+and+classification+of+errors%3a+NQF+Taxonomy+Training+on+reporting+events%2c+conducting+analysis%2c+action+plans+Review+aggregate+data+Allow+for+meaningful+changes%2c+improvement%3a+NQF+revisions+Feedback+to+reporting+facilities%3a+lessons+learned%3b+best+practices+Electronic+reporting%0d%0a%0d%0a%0cPrevention%0d%0a%ef%81%b5+Patient%0d%0a%0d%0aSafety+Assessments+in+Ambulatory+Care%0d%0a%e2%80%93+Involvement+of+insurers+%e2%80%93+Using+assessment+data+to+facilitate+behavior+change%0d%0a%0d%0a%ef%81%b5+Research%0d%0a%0d%0apatient+safety+practices+of+Massachusetts+General+Hospital+and+state+of+Minnesota%0d%0a%0d%0a%0cCompensation+Systems+for+Medical+Injury%0d%0a%ef%81%b5%0d%0a%0d%0a%ef%81%b5%0d%0a%0d%0a%ef%81%b5%0d%0a%0d%0aStudy+effects+of+disclosure+on+settlement+and+experiences+under+Wyoming%e2%80%99s+%e2%80%9cI%e2%80%99m+Sorry%e2%80%9d+law+Review+Wyoming%e2%80%99s+medical+malpractice+claims+data+Review+existing+laws+for+participation+in+federal+pilot+programs%2c+early+offers%0d%0a%0d%0a%0c
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issues in medical errors
Rated 10 out of 10

June 25, 2008 (3 months 16 days ago)very helpfull document