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Prevention of Medical Errors

Prevention of Medical Errors. KIMBERLY REED, O.D., FAAO. No financial disclosures. Welcome. Goals Fulfill obligation as licensed optometrists Promote wellness as individuals Course Overview and Format Medical Errors Statistics Types/definitions Hospital based errors Medication errors

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Prevention of Medical Errors

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  1. Prevention of Medical Errors KIMBERLY REED, O.D., FAAO No financial disclosures

  2. Welcome • Goals • Fulfill obligation as licensed optometrists • Promote wellness as individuals • Course Overview and Format • Medical Errors • Statistics • Types/definitions • Hospital based errors • Medication errors • Root cause analysis and prevention • EMR/EHR • Help or hindrance?

  3. Florida’s requirements • Florida Rule 64B13-5.001 (8) • Last updated 2006 • “Must include a study of root-cause analysis, error reduction and prevention, and patient safety”

  4. Errors made by our colleagues • Dilated with 1% tropicamide? • Samples of artificial tears? • Expired samples

  5. IOM, 1999: To Err Is Human: Building a Safer Health System • Between 44,000 and 98,000 people die every year due to preventable errors in U.S. hospitals

  6. Responses to IOM Report • CE requirements • Mandatory or voluntary systems for reporting medical errors (National Quality Forum, 2007) • Joint Commission (JCAHO) requires healthcare institutions to analyze errors using root cause analysis

  7. Responses to IOM Report • Patient Safety and Quality Improvement Act (database) • Centers for Medicare and Medicaid Services – will not reimburse hospitals for treatment of 8 preventable errors • Medicaid, Aetna, BCBS, etc. following suit

  8. Healthcare Associated Infections (HAI) • 100,000 deaths per year • Leading complication of hospital care

  9. Agency for Healthcare Research and Quality • AHRQ.GOV • $50 million annually to research patient safety • Grants ranging from $400 – 1.2M to study HAI prevention

  10. Postoperative sepsis per 1000 elective-surgery

  11. Based on income….postoperative sepsis • Lowest income • Highest income • Self pay • Medicaid

  12. Children who needed care right away who didn’t get it

  13. White • Hispanic • Black • English speaking • Non-English speaking

  14. Responses to IOM report • President Clinton tried to implement mandatory reporting system for medical errors • Lobbied against by AMA and AHA • 81 million dollars • “If medical errors and infections were better tracked, they would easily top the list {of cause of death in the U.S.}. In fact, a visit to your doctor or a hospital is twice as likely to result in your death [than] a drive on America’s highways.”

  15. Where are we now? • IOM set a goal of 50% reduction in errors by 2004

  16. HealthGrades Patient Safety (2004) • Study of 37 million patient records, all Medicare, in 50 states + DC. • Medicare 45% of all hospital admissions excluding OB • 195,000 deaths annually due to in-hospital medical errors (2000-2002) • Since the original report in 1999: • 1 - 2 million more people have died due to preventable medical errors or hospital-acquired infection

  17. January 2012 report • Reported January 6 in NY Times • Department of Health and Human Services • Medicare patients • Hospitals are required to track medical errors and adverse patient events and conduct a root cause analysis • Records review by independent doctors • How many medical errors are reported?

  18. Recalculating…….recalculating….. • 130,000 Medicare beneficiaries experience one or more adverse events in hospitals • EVERY MONTH

  19. Raleigh General Hospital, W.Va. • Anesthetic Awareness • Patients can feel all the pain, pressure, discomfort during surgery…but cannot move or communicate with doctors • Occurs between 20,000 and 40,000 patients every year • Attributed to physician error or faculty equipment • Sometimes only part of the drugs are administered • W.Va. Patient committed suicide

  20. Who makes the IV bags? • Two year old girl receiving IV chemo • Saline base prepared before adding chemo agents • Saline was 20 times stronger than ordered • High concentration of sodium caused brain edema and coma • Child died 3 days later

  21. Who makes the IV bags? • Pharmacy tech • High school diploma • Pharmacist overseeing the work was fired, convinced of involuntary manslaughter • Jail time • House arrest • Loss of license, career • Fined

  22. Who makes the IV bags? • Pharm techs have something to do with approximately 96% of pharmacy prescriptions • “Culture of Silence”

  23. Who is “attending” you? • Medical Model Education • Student/intern? • Resident? • Chief resident? • Attending?

  24. Who is “attending” you? • Fatal oversight: • Second year student doing “rounds” at UPenn • 71 year old patient recovering from hip replacement surgery • SOB, sweating • Classic signs of pulmonary embolism • “I hadn’t read that chapter yet” • Patient died

  25. Adding to the problem • Most people feel that medical errors are the failures of individual providers • Delays in diagnosis and treatment? • But… • IOM showed most medical errors are “systems related”

  26. Why do medical errors occur? • “Systems” errors • Fatigue* • Brigham and Women’s & Harvard • 3x higher error rate with 1x/ month 24 hour shift • 7x higher error rate with 5x/month 24 hour shifts • Lack of knowledge • 6000 known diagnoses • 4000 available drugs • Lack of communication *www.plosmedicine.org

  27. Why do medical errors occur? • Poor charting • Impaired care providers • Survey of 1662 respondents • 46% failed to report at least one serious medical error • 45% failed to report an incompetent or impaired colleague *www.plosmedicine.org

  28. Root Cause Analysis • “A process for identifying the basic factors that underlie variation in performance, including the possible occurrence of a sentinel event.” • Focuses on systems and processes, not on individual performances

  29. A Case with a Bit More Relevance • “The fiasco which left seven veterans blinded” • Vawatchdog.org • 62 year old male veteran suffered “significant visual loss in one eye as a result of poorly controlled glaucoma” • January 2009

  30. A Case with a Bit More Relevance • In June 2005, the patient was diagnosed as a “glaucoma suspect” • Allegedly, treatment wasn’t initiated • Prompted a review of 381 charts • 23 glaucoma patients experienced “progressive visual loss” while receiving treatment in the Optometry department • Root Cause Analysis: • Patients were not being sent to ophthalmology for treatment (required by hospital) • Some OD’s did not hold additional certification to treat glaucoma

  31. Reality Check – August 9 2010 Archives of Internal Medicine • Do patients know the name of the doctor overseeing their care?

  32. How many patients know their diagnosis? • Doctors said • Patients said

  33. Adverse effects of drugs were discussed with patients? • Doctors said • Patients said

  34. Fears and anxieties • “At least sometimes I discussed patients’ fears and anxieties with them” (doctors) • “I had fears/anxieties but I didn’t discuss them with my physician.” (patients)

  35. Preventing Medical Errors

  36. Partnership for Patients • Coalition between 2,900 hospitals and federal administration • Goal: Reduce medical errors and save 60,000 lives in three years

  37. Reporting Errors • 27 states have laws that require hospitals to report publicly on infections that are developed in the hospital • In 2005, only 5 states participated • Obama administration not proposing new federal requirements for reporting

  38. What can the patient/consumer do to help reduce errors? • Appoint a patient advocate! • Verify patient’s identity every time a care provider interacts with patient • Keep a log of doctor and nurse visits and instructions • Get results of all tests and labs • Write down all information pertinent to diagnosis, treatment, and care • ESPECIALLY medications ordered and dispensed • Keep a medication log of at-home and hospital-prescribed medications • Infection Control!

  39. What can the patient/consumer do to help reduce errors? • Be your own advocate • Choose your hospital wisely • Most people choose based on doctor’s affiliations, location, or health plan • Big differences in hospitals: Up to a 30% difference in central-line infections from hospital to hospital • INFECTION CONTROL!

  40. What can the patient/consumer do to help reduce errors? • Be mindful of your own medications • Drug errors are a leading cause of error • Bring a list of meds and dosages and keep one with you during transfers, etc • Know side effects and potential interactions • Know where your advocate keeps your medication log

  41. What can the patient/consumer do to help reduce errors? • If you have a choice, choose a hospital using bar-coding to verify patient identity, medication instructions, etc. • If permitted, label everything you can with patient’s name

  42. What can the patient/consumer do to help reduce errors? • Avoid wrong-site surgery • Write on your arm/leg/forehead “Operate here” • INFECTION CONTROL! • Make sure everyone touching the patient washes their hands • Clean common items in the hospital room such as television remotes, chair handles, door handles, etc. • Do not allow flowers to be near the patient

  43. Hand washing • Video monitoring improved compliance by 40%

  44. 2011 study 57 • 63% of health care workers’ uniforms have CFU’s • 11% multiple antibiotic resistance • Neckties

  45. Stethoscopes? 58 • 1997 study • 100% of physicians’ stethoscopes had CFU’s • Mostly staph, strep • simple swabbing with alcohol pad reduced growth to non-pathogenic • 2011 study of ER workers’ stethoscopes • 55% had CFU’s • Mostly staph epi

  46. EEWWWWW 59 • 2010 study • Culture-forming units on • 66% pens • 55% stethoscopes • 48% cell phones • 28% white coats

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