Identifying and Addressing Adverse Events in Pediatrics

1. Elvis Is Dead and I Don’t Feel So Good Myself Gerald B. Hickson, M.D. Associate Dean for Clinical Affairs gerald.hickson@vanderbilt.edu Center for Patient & Professional Advocacy www.mc.vanderbilt.edu/cppa

2. Why focus on identifying and addressing adverse events and risk?

3. Principles • Errors and harm are not always linked • No shortage of patient injuries (whether caused by errors or not) • Prudent to give first priority to finding and addressing those situations that actually give rise to injury or risk

4. So what do we know about the causes of adverse medical outcomes?

5. Methods • Identify RM files for inclusion 1996-2001 • 116 Risk Management files opened out of 820,000 pediatric visits (<0.02%) • Prepare Cause and Effect Diagrams • Code the Causes • Aggregate the code Hain PD, Pichert JW, Hickson GB, Bledsoe SH, Hamming D, Hathaway J, Nguyen C: Using Risk Management Files to Identify and Address Causative Factors Associated with Adverse Events in Pediatrics. Therapeutic & Clinical Risk Management (in press)

6. Cause-Effect Diagram People Procedure Equipment Adverse Outcome Environment Policy Other “Ichikawa Diagram”

8. 1996-2001 Pediatrics (n=116) Number of Cases Confidential and privileged pursuant to TCA section 63-6-219

9. So what kinds of communication failures do we have among members of our team? Let’s review a case…

10. We can’t stop the Sz • KP-16 mo male with sudden onset of fever to 105° • Parents call 911, transported to closest ED (40 minutes from children’s hospital) • ED at CH called: “Status epilepticus I hr duration…can’t get in line, can you help?”

11. We can’t stop the Sz • CH ED Attending (23:00): • Knows CH really busy, hospital and ICU are full • Knows “there is always a bed in ICU” (policy) • Calls ICU attending to discuss transfer, who responds, “just can’t take pt…we are full.”

12. We can’t stop the Sz • ED attending weighs the pros and cons, transport arranged • KP arrives in status (00:30): T - 100.5°, P – 179, R – 33, BP 91/38 • Two lines inserted, multiple doses of multiple anticonvulsives administered • CT – neg; LP - neg • Needs admit to ICU. ICU called for admission.

13. We can’t stop the Sz • Conversation between ICU and ED attending is described as “challenging” • ICU attending: “I told you – NO BEDS. Why did you accept pt?…You will just have to arrange transport somewhere else…hangs up” • Vitals: T – 101, P – 180, R – 36, BP 78/32

14. We can’t stop the Sz • Air transport arranged • Vitals at lift off (04:40): P – 85, R – 30, BP – 59/25 • On arrival at 2nd CH (05:00)– pt started on dopamine…no response

15. We can’t stop the Sz • Receiving ICU attending; “I can’t believe…” • Hypoxic ischemic brain injury • Family filed suit – Allegation; failure to rescue (we paid real $$s)

16. Cause-Effect Diagram People Procedure Equipment Adverse Outcome Environment Policy Other “Ichikawa Diagram”

17. Let’s Examine Several “Causes” in Some Detail • Coordination of service delivery • Chain of command • Environment - busy • “A policy” – one open bed • Ineffective communication • “Disruptive behavior” – hanging up on a colleague?

18. SBAR • A standardized format to transfer info: • Situation • Background • Assessment • Recommendation • VUMC SBAR Policies: Hand-Off Communication, CL 30-08.04; Rapid Response Team, CL 30-08.16 • SBAR Literature: Weinger MB, et al:  Qual Saf Health Care 2004;13:136; Weinger MB, Slagle J: JAMIA 2002; 9: S58; France D, et al. AORN J 2005; 82: 214; Grogan E, Stiles RA, France DJ et al. J Am Coll Surg 2004; 199: 843.

19. What constitutes disruptive behavior?

20. What Constitutes Disruptive Behavior? Behavior that interferes with…work…or creates… hostile…environment: • verbal abuse, sexual harassment, inappropriate demands; • yelling, profanity or vulgarity; • unwelcome physical contact; assault/battery • threats of harm; behavior reasonably interpreted as threatening (verbal, written or physical); • behavior causes stressful or traumatic incidents that interfere with others’ effective functioning. Vanderbilt University and Medical Center Policy #HR-027

21. How can you forget to do that? You’re a worth-less resi-dent. Hmm. I better give them perfect evals so they don’t kill me!

22. “I don’t have a problem with anger. I have a problem with idiots.”

23. “Why do we need to do anything anyway?” “Dr. ____ is technically outstanding (just a bit challenging)…”

24. Spectrum of Disruptive Conduct: Patient Perspective (tip of the iceberg) Lawsuits VoicedComplaints Errors Drop out Non adherence

25. Why Might a Medical Professional Behave in Ways that are Disruptive?

26. 1. Substance abuse, psych issues 2. Narcissism, perfectionism 3. Spillover of family/home problems 4. Poorly controlled anger (2° emotion)/Snaps under heightened stress, perhaps due to: a. Poor clinical/administrative/systems support b. Poor mgmt skills, dept out of control c. Back biters create poor practice environments Why Might a Medical Professional Behave in Ways that are Disruptive?

27. The World ME Scientific evidence proves the world does revolve around me

28. Why Might a Medical Professional Behave in Ways that are Disruptive? The Point If the organization wants to help or “redeem” the professional, the intervention is best done when based on a conceptual framework, sound policies, good assessment tools, strong leadership, and training in the “how to”.

29. Disruptive Behavior Pyramid Level 3 "Disciplinary" Intervention No ∆ Pattern persists Level 2 "Authority" Intervention Apparent pattern Level 1 "Awareness" Intervention Single “unprofessional" incidents(merit?) "Informal" Intervention Mandated Issues Vast majority of doctors—no issues

30. Upcoming CPPA Conferences at Vanderbilt: The Why and How of Dealing with “Special” Colleagues: Discouraging Disruptive Behavior June 28-29, 2007; November 8-9, 2007 The How and When of Communicating Adverse Outcomes and Errors August 16-17, 2007; February, 2008 http://www.mc.vanderbilt.edu/CPPA

31. Questions? Comments? www.mc.vanderbilt.edu/CPPA