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Patient Safety: How You Can Prevent Medical Errors

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Patient Safety: How You Can Prevent Medical Errors

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    1. Patient Safety: How You Can Prevent Medical Errors Arpana R. Vidyarthi, MD Associate Professor of Clinical Medicine Director of Quality and Safety Programs, GME I am lucky to be the second person to welcome you to UCSF, and I have to say, I am very excited that you are here…I hope that most of you are also excited axious but mostly exicited about starting internship—which I guarentee will be one of the most challenging, exhillarating, and rewarding year’s of your life, but I know that there is one more group—not represented here, the outgoing interns, who are thrilled at your presence. So on behaaf of them—welcome!I am lucky to be the second person to welcome you to UCSF, and I have to say, I am very excited that you are here…I hope that most of you are also excited axious but mostly exicited about starting internship—which I guarentee will be one of the most challenging, exhillarating, and rewarding year’s of your life, but I know that there is one more group—not represented here, the outgoing interns, who are thrilled at your presence. So on behaaf of them—welcome!

    2. Why Are You Here? “…my time in the developing world led me to…” “…the scientific exchange that I experienced in the lab…” “…UCSF’s reputation…” You have spent decades of education getting to this point—and here you are—about to embark upon direct responsibility for patient care—in our zeal to help people— I know you are sitting here worried—do I know enough, how will I remember that diagnosis, or how to throw that tie. I will posit to you, that to achieve this goal, you need to not only think about those things, but consider another aspect of the care we deliver—and You have spent decades of education getting to this point—and here you are—about to embark upon direct responsibility for patient care—in our zeal to help people— I know you are sitting here worried—do I know enough, how will I remember that diagnosis, or how to throw that tie. I will posit to you, that to achieve this goal, you need to not only think about those things, but consider another aspect of the care we deliver—and

    3. The Institute of Medicine: 44,000 – 98,000 preventable adverse events yearly No patient safety talk would be complete without discussing the 1999 IOM report to err is human. Hopefully this isn’t the first you are hearing about this report—but over a decade ago, this report heralded the nature of what has been termed the epidemic of medical errors to healthcare providers, patients, legislators and everyone in between. not only did it bring these data to a wide audience-made it accessible and palpable. 4th leading cause of death in the US—admission to a hospital $17 billion are associated with preventable errorsNo patient safety talk would be complete without discussing the 1999 IOM report to err is human. Hopefully this isn’t the first you are hearing about this report—but over a decade ago, this report heralded the nature of what has been termed the epidemic of medical errors to healthcare providers, patients, legislators and everyone in between. not only did it bring these data to a wide audience-made it accessible and palpable. 4th leading cause of death in the US—admission to a hospital $17 billion are associated with preventable errors

    4. Medical Care…Then and Now marcus welbymarcus welby

    5. First Do No Harm Safety of patients is our priority ….and we could be doing a better job! Maybe the most common thing you will do every day: write ordersMaybe the most common thing you will do every day: write orders

    6. Individual Errors Are Common, And Expected Slips Errors involving semi-automatic routines daily activities exacerbated fatigue, competing tasks Mistakes Errors in interpretation, misapplication of cognitive rules more likely in new or unusual situations

    7. The “Swiss Cheese Model” of Major Accidents & Errors

    8. What Type of Human Glitches Cause Harm?

    11. What is Our Goal? Freedom from accidental injury due to medical care, or medical errors Patient Safety What about safety today—well—initial data shows that we are more aware, but not quite making an improving grade—complexity of course. What about safety today—well—initial data shows that we are more aware, but not quite making an improving grade—complexity of course.

    12. So What Can You Do About It? Use Communication Tools Be Conscientious of Signouts If you see something wrong, tell someone Strategies to improve the safety of your patients, from your front line provider perspective, isn’t really rocket science. I am going to go through 3 discrete strategies that you can use right away, next week when you are seeing patients—inpatients, outpatients, on the wards, and in the OR. 1,2,3Strategies to improve the safety of your patients, from your front line provider perspective, isn’t really rocket science. I am going to go through 3 discrete strategies that you can use right away, next week when you are seeing patients—inpatients, outpatients, on the wards, and in the OR. 1,2,3

    13. Communication Tools Read back for all verbal orders Standardization for order sets OR Time-Outs SBAR For urgent or high-risk orders, make sure to speak to the nurse directlyFor urgent or high-risk orders, make sure to speak to the nurse directly

    14. Case Presentation: Edith presents with SOB

    15. Day 1

    16. Day 2

    17. The first 48 hours of Edith’s stay…. Resident: “Do you remember us Edith, we are the doctors taking care of you?” Edith: “Uh….no?” Resident 5 to intern: “She seems altered. Let’s get a stat head CT.” How many of you have ever played the game operator? If you have, I don’t even have to make an argument about the potential for errors with handoffs.How many of you have ever played the game operator? If you have, I don’t even have to make an argument about the potential for errors with handoffs.

    18. Why So Many Handoffs Today? ACGME duty hour limitations 80 hours per week 30 hours continuous 24 hours off per month Practicing physicians Group practices: cross-coverage Hospitalists Days of residency—new look—in an effort to primarily reduce the errors associated with resident fatigue, ACGME-the body that accredits residencies, reduced the number of hours that residents across disciplines could work. IM residency 1 month rotations, internship, signout more than the number of patients that they will admit in their entire internship, more than the largest order that they will write (bolus of saline) more than the freuqency that they will eat in a month—300/month. Think in patient and outpatinet Turnover: LOS, outpatientDays of residency—new look—in an effort to primarily reduce the errors associated with resident fatigue, ACGME-the body that accredits residencies, reduced the number of hours that residents across disciplines could work. IM residency 1 month rotations, internship, signout more than the number of patients that they will admit in their entire internship, more than the largest order that they will write (bolus of saline) more than the freuqency that they will eat in a month—300/month. Think in patient and outpatinet Turnover: LOS, outpatient

    19. Housestaff Experiences “handoffs are dangerous” A common suboptimal care practice 59% report patient harm Increased errors from discontinuity Clinical Delayed test ordering Increased in-hospital complications Increased medication errors Presumed increase in length of stay Perceptions Impacts Numerous articles have been published in a vareity of disciplines addressing resident perceptions regarding handoffs. In general, these points summarize some of the conclutionsNumerous articles have been published in a vareity of disciplines addressing resident perceptions regarding handoffs. In general, these points summarize some of the conclutions

    20. Discontinuity and Patient Harm Most significant risk for an adverse event: cross-covering MD

    21. Handoff Best Practices University Health Consortium Position Papers IM, ER, Surgery, Hospital Medicine Society of Hospital Medicine Joint Commission

    24. Communication Channels

    25. Think About What You Would Want To Know Who What Administrative Data Problem list To Do List Nuance Where

    26. What Can You Do To Diminish Harm at Signouts? Take it seriously…we do Use standardized tools…they work Verbally sign out…it matters Role model…remember yesterday

    27. Individual Errors Are Common, And Expected Slips Errors involving semi-automatic routines daily activities exacerbated fatigue, competing tasks Mistakes Errors in interpretation, misapplication of cognitive rules more likely in new or unusual situations Remember this? well, I don’t know about you, but these are the sorts of things that I do everyday…and given the fact that the swiss cheese has holes, every once in a while, something bad will happen, or might happen to a patient just because I am human. It isn’t just about humans, but also the systems that we have in place—they just don’t work—in fact our own research shows that more than 1/3 of you have experienced a medical error. Remember this? well, I don’t know about you, but these are the sorts of things that I do everyday…and given the fact that the swiss cheese has holes, every once in a while, something bad will happen, or might happen to a patient just because I am human. It isn’t just about humans, but also the systems that we have in place—they just don’t work—in fact our own research shows that more than 1/3 of you have experienced a medical error.

    28. So What Do You Do When…? Report problems Incident reports/near miss reports Let us know: arpana@medicine.ucsf.edu, Tell your chief residents! Don’t fear the RCA Chiefs—meet with GME and hospital leadership monthly Near miss reporting (anesthesia) Hospital IR reports are followed up by every department Resident & Fellows Committee, CPOEChiefs—meet with GME and hospital leadership monthly Near miss reporting (anesthesia) Hospital IR reports are followed up by every department Resident & Fellows Committee, CPOE

    29. Case Review: To Fix the System… Medical center level Multi-disciplinary Clinical Events Oversight Committee Systematic review of the events including participants with actions Department/division based Single discipline M and M/Peer Review/Case Review Discussion and review by peers Root Cause Analysis Case Review-Peer Review Apparent cause analysisApparent cause analysis

    30. Engage the Process… You are the one with the knowledge: events Clinical Operational Systems You are the one with knowledge: solutions Experience Feasibility Culturally applicable

    31. Safety and Quality Today… Freedom from accidental injury due to medical care, or medical errors The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Safety Quality What about safety today—well—initial data shows that we are more aware, but not quite making an improving grade—complexity of course. What about safety today—well—initial data shows that we are more aware, but not quite making an improving grade—complexity of course.

    32. And on the Quality Front… Table 3. Adherence to Quality Indicators, Overall and According to Type of Care and Function. McGlynn and colleagues from rand corporation 20,000 geographically diverse patients almost 500 quality indicators Tranisition—man made epidemic—we don’t’ have to wait for a sceintific Table 3. Adherence to Quality Indicators, Overall and According to Type of Care and Function. McGlynn and colleagues from rand corporation 20,000 geographically diverse patients almost 500 quality indicators Tranisition—man made epidemic—we don’t’ have to wait for a sceintific

    33. UCSF Programs to Improve Quality Curriculum in your department Opportunities for Q/S projects Resident engagement on committees Patient Care Fund Resident Quality and Safety Committee

    34. UCSFMC/GME Incentive Program

    35. Program Specific Incentives Anesthesia Increase rate of prophylactic antibiotics Dermatology Decrease clinic wait times EM Increase PCP communication Peds Asthma action plans Neuro Improve swallow exams on stroke pts Medicine Increase PCP communication Neurosurgery Ontime start in the OR ObGyn Improve DM orders Radiology Critical results reported

    36. Safety and Quality are About Systems Problem in healthcare = assumption of individual responsibility/blame for errors Must recognize that medicine is a team effort, involving MD’s, nurses, pharmacists, etcProblem in healthcare = assumption of individual responsibility/blame for errors Must recognize that medicine is a team effort, involving MD’s, nurses, pharmacists, etc

    37. Safety and Quality are About Systems Problem in healthcare = assumption of individual responsibility/blame for errors Must recognize that medicine is a team effort, involving MD’s, nurses, pharmacists, etcProblem in healthcare = assumption of individual responsibility/blame for errors Must recognize that medicine is a team effort, involving MD’s, nurses, pharmacists, etc

    38. You Can Change The Script Prioritize safety in your everyday work Use communication tools Signout patients with care Report problems you see Ask for help! Think about the quality of care provided Engage the systems Think back to just a few weeks ago—one of the foundational tenents of the oath that many of you took is to first do no harm. And think to years ago—your goals…qualtiy and safety is a main way that we can Think back to just a few weeks ago—one of the foundational tenents of the oath that many of you took is to first do no harm. And think to years ago—your goals…qualtiy and safety is a main way that we can

    39. THANKS

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