Prevention of Medical Errors FS 456.013(7)

1. Prevention of Medical Errors FS 456.013(7) A Risk Management Seminar for Physicians Indiana Osteopathic Association December 8, 2012 Presented by Debra Davidson, MJ, ARM, CPHRM Patient Safety Department

2. Disclosure • We would like to disclose that Debra Davidson, as an employee of The Doctors Company, has a financial interest in The Doctors Company, an organization that may have a direct interest in the subject matter of this CME presentation. Prevention of Medical Errors / 2

3. Course Objectives At the conclusion of this presentation, participants will be able to: • Describe a root-cause analysis • Recite the most “misdiagnosed” conditions • Recognize medical error reduction and prevention measures • Identify patient safety goals • Meet the requirements of FS 456.013(7) Prevention of Medical Errors /

4. Prevention of Medical Errors /

5. Error Definition • Adverse Event: Injury caused by medical management rather than the underlying illness or condition of the patient • Malpractice: Failure to exercise that degree of care used by reasonably prudent physicians in the same or similar circumstances • Medical Error: A preventable adverse event Prevention of Medical Errors /

6. Prevalent Medical Errors • Nosocomial Infections=103,000 deaths/year1 • Medication errors=1.5 million people/$3.5 billion2 • Medication errors=7,000 deaths/year2 • Allergic reactions=700,000 to ER/year3 • Simple errors=27,000 deaths/year4 • Wrong Surgeries=1,700-2,700/year5 • 1 in 20 admissions=preventable adverse event 1. IOM 2. FHA/ASHRM 3. JAMA (10/2006) 4. PIAA Newsbriefs 10.16.2006 5. Archives of Surgery (Sept. 2006) Prevention of Medical Errors /

7. “Errors must be accepted as system flaws, not character flaws” —Lucien Leape, M.D. Prevention of Medical Errors /

8. Root Cause Analysis • Structured and process-focused framework • Credible and thorough • Active and latent–what, how, and why • Specific underlying causes • Reasonably identifiable • Controlled or influenced • Generate specific recommendations • Primary aim: Avoid culture of individual blame Prevention of Medical Errors /

9. Root Cause Analysis (continued) Implementation 1. _______ Measurement of Effectiveness 2. _______ 3. _______ Prevention of Medical Errors /

10. Root Causes—Medical Errors • Communication factors • Unclear lines of authority • Highly variable settings • Varied health care processes • Time pressured environment • System deficiencies • Vulnerable defense barriers • Human fallibility National Patient Safety Foundation Prevention of Medical Errors /

11. Most Misdiagnosed Conditions • FAC 64B8-13.005(c) (MD)FAC 64B15-13.001(3)(f) (DO)* • Wrong site/wrong procedure surgery • Cancer • Cardiac conditions* • Inappropriate opioid prescribing* • Neurological conditions • Acute abdomen related conditions • Timely diagnosis of surgical complications • Diagnosis of pregnancy related conditions Prevention of Medical Errors /

12. Prevalent Types of Error • Communication Errors • System Errors • Medication Errors Prevention of Medical Errors /

13. Most prevalent root cause of • medical errors is communication Prevention of Medical Errors /

14. Prevention of Medical Errors /

15. Communication Errors • Failure to educate and inform • Miscommunication • Health literacy issues • Failed crucial conversations • Communication barriers • Physical • Emotional • Cultural Prevention of Medical Errors /

16. Effective Communication • Patients usually interrupted after ____? • On average, patient would speak _____? • Short-term investment=long-term payoff • Improved compliance • Focused interactions • Realistic expectations • Enhanced rapport Prevention of Medical Errors /

17. What’s the Trouble? How doctors think. by Jerome Groopman, January 29, 2007 Most physicians already have in mind two or three possible diagnoses within minutes of meeting a patient. Prevention of Medical Errors / The New Yorker

18. Low Health Literacy • 90 million people have literacy related health risks • 1 out of 5 read at a _______ grade level • 50 percent understand directions for taking medications correctly www.npsf.org Prevention of Medical Errors /

19. Prevention of Medical Errors /

20. Clinician/Clinician Communications • Referrals • Diagnosticians • Surgical clearance • Hospitalists • Hospitalization • Handoff: SBAR Report • Situation • Background • Assessment • Response CHAIN OF COMMAND Prevention of Medical Errors /

21. Smart phones Prevention of Medical Errors /

22. Eye contact Slow down Listen Language Visual aids Limit and repeat Ask Me 3 Verify with teach back Communication Error Prevention • Patient-centric culture • Awareness • Team building • Training • Protocols–checklists Prevention of Medical Errors /

23. Preventing Communication Errors Prevention of Medical Errors /

24. System Errors • Increase with medical complexity and numbers involved • Prevalent adverse events • Missed diagnosis • Improper performance–wrong surgery Prevention of Medical Errors /

25. System Error: Missed Diagnosis • Most prevalent conditions • Cancer • Cardiac • Neurologic condition • Acute abdomen • Complications–Pregnancy • Addiction, psychiatric conditions and diversion Frequently a concurrent condition Prevention of Medical Errors / American

26. Inadequate follow-up system Failure to define parameters Inadequate assignment of care management Faulty communication of clinical concerns Missed Diagnosis Root Causes • Personal bias • Haste • Misguided axioms • Poor history • Inadequate exam • Failed evaluation and pursuit Prevention of Medical Errors /

27. Missed Diagnosis: Cancer • Most prevalent missed diagnosed condition • 60%–Serious injury1 • 30%–Death1 • 50%–PCP1 • 2/3–Cancer1 • 30%–two or more clinicians Annals of Internal Medicine 4/2006 Prevention of Medical Errors /

28. Missed Diagnosed Cardiac Conditions • 93%–Chest pain • 59%–ECG ordered • 50%–ECG misdiagnosed • 20%–No study • GI most common diagnosis • <31% attributed a cardiac origin 77%–Died as a result of dx and tx errors PIAA AMI Claims Study • Prevention of Medical Errors /

29. Missed Diagnosis: Neurologic Condition • Clinical examination • Age • Traditional vascular risk factors • Significance of presenting complaints • Vomiting • Neurologic examination • Gait testing • Vision • Fixation on other medical conditions Prevention of Medical Errors / PIAA AMI Study

30. Missed Diagnosis: Neurologic Condition (continued) • Diagnostic testing • Failure to perform brain imaging • Failure to recognize limitations in imaging • Failure to pursue other diagnostics • Failure to consider in-hospital observation • Failure to obtain neurologic consultation Prevention of Medical Errors /

31. Missed Diagnosis: Acute Abdomen • Appendicitis • Esophageal varices • Abdominal aortic aneurysm • Peptic ulcer disease • Hernia of abdominal wall • Cholecystitis/lithiasis • Ectopic Pregnancy • Diverticulosis • GERD • Renal stones • SBO • Hiatal hernia • PID • Pancreatitis • Colitis • IBS • Gastroenteritis • Encountered in 5-10% of all ER visits PIAA Data Sharing System Report 1985-2007 Prevention of Medical Errors /

32. Missed Diagnosis: Pregnancy and Its Complications • Failure to diagnose • Ectopic Pregnancy • Gestational Diabetes • Pre-Eclampsia/Eclampsia • Failure to diagnose pregnancy prior to treatment • Routine radiology • Invasive diagnostics • Medications deemed high-risk for pregnancy • Other pertinent treatment initiatives Prevention of Medical Errors /

33. Diagnostic Error Prevention • Triage–H&P · • Evaluate and document signs and symptoms • Diagnostic pursuit–index of suspicion • Define parameters • Referral and follow-up · • Clarify responsibilities • Manage non-compliance • Monitor follow-up appointments Prevention of Medical Errors /

34. Diagnostic Error Prevention (continued) • Childbearing–testing • Communicate and document plan • Education • Diagnostics • Treatment • Follow-up • Diagnostics • Physician review • Communicate • Tracking/Recall Prevention of Medical Errors /

35. Diagnostic Error Prevention (continued) • Tracking and recall systems • Failure to follow up diagnostic results–significant • 80%–one delay in reviewing results over two months • 1 in 5=delays >five times • 30%–medical practices fail to document review • Approximately 74 minutes/day managing results Archives of Internal Medicine. 2009;169(17):1578-1586. Prevention of Medical Errors /

36. LABORATORY CMP BMP Electrolyte Panel Hepatic Function Panel Lipid Panel Obstetric Panel Hepatitis Panel CBC PT w/ INR Hemogram Amylase FSH Glucose________ PSA TSH_________ UA Data Pending Patient:Date: ___ ____ • SPECIMENS • Pap • C&S • Biopsy • RADIOLOGY • Chest X-ray • MMG • DEXA • US • ___ CT/MRI____ Referral Notes/Records ________ Referrals ________ Records Prevention of Medical Errors /

37. Prevention of Medical Errors /

38. System Error: Wrong Surgery • 58% ambulatory settings • 29% in-patient OR • 13% other in-patient settings–ER, ICU • 76% wrong body part or site • 13% wrong patient • 11% wrong surgical procedure • ________________________________________ • Communication–78% of cases • Orientation and training–45% of cases Joint Commission on Accreditation of Healthcare Organizations Prevention of Medical Errors /

39. Wrong Surgery Root Causes • Communication breakdown • Poor patient preparation • Wrong information provided by patient/parent • Errors in consent form and medical records • X-ray interpretation and report language errors • Emergent situations • Unusual time pressure, equipment, or set-up • Morbid obesity • Multiple procedures–multiple surgeons • Clinician error Prevention of Medical Errors /

40. Case Summary • Two (F) patients scheduled for breast surgery on 2/14 by same surgeon • Surgeon arrived after first patient prepped and draped • Performed (R) total mastectomy due to breast cancer • Enters holding area–met by nurse and informed that his mastectomy patient was “ready” • First patient scheduled for right breast biopsy only • Suit • Disciplinary action Prevention of Medical Errors /

41. Prevention of Medical Errors /

42. Surgical Complications • Most claims have acceptable medical complications • Failure to supervise/monitor post-op most prevalent root cause of medical error • Prevalent post-op complications: • Infection • Perforation • Suture failure • Bleeding • Foreign body retention–res ipsa loquitur Prevention of Medical Errors /

43. Case Summary • HX: 52 y/o male w/ hx of sleep apnea. Obese. Smoker. • Procedures: R inguinal hernia repair, abdominoplasty, blepharoplasty • Orders: Morphine 4 mg IV q 4 h prn. • Valium 2 mg IV q 4-6 h prn. • Monitor. I&O. SCDs. Ambulate ASAP. • Actual Care: Morphine 4 mg IV q 2 h. Valium 2 mg IV q 2 h. • Outcome: Patient agitated. Restless. Oxygen sats. dropped. SOB. Vomited. Aspirated. Respiratory arrest. Code initiated unsuccessfully. Patient expired. Prevention of Medical Errors /

44. Prevention of Medical Errors /

45. FAC (2) “…requiring the team to pause.” (b) “…The notes of the procedure...” Florida Statute 456.072(1) …“Performing or attempting to perform… … includes the preparation of the patient. Wrong-Site Surgery Prevention of Medical Errors /

46. Department of Health • Wrong-Site Sanctions (first offense) • Letter of Concern • $5,000 fine • Costs of investigation and processing (@$2,500) • Five CME’s Risk Management • One hour lecture–develop and deliver Prevention of Medical Errors /

47. In the News… • Text of Duke's Letter to UNOS Explaining Transplant Mistakes • Posted: Feb 21, 2003 Durham, NC—The following letter was sent Friday to the United Network for Organ Sharing (UNOS). • Duke University Hospital has completed the initial phase review of the events related to the heart/lung transplant from donor _______. We provide the following to promote our joint efforts in the peer review of this incident and for the purpose of performance improvement. • We have concluded that human error occurred at several pointsin the organ placement process that had no structured redundancy. Prevention of Medical Errors /

48. West Boca High cheerleader got fraction of drug needed, lawyer charges Prevention of Medical Errors /

49. Surgical Error Prevention • Identification • Technology–bar-coding/photo ID • Verification protocol • Mark site • Patient education and preparation • Consent/Education • Prophylactic ATB • Protocols • Training Prevention of Medical Errors /

50. Surgical Error Prevention (continued) • Document normal and abnormal findings • Pre and Post-evaluations • Pre and Post-diagnostics • Pre and Post-instruction • Follow-up • Supervision • Team building • Communications Prevention of Medical Errors /