Patient Safety and the M edical P ractice of House O fficers

1. Patient Safety and the Medical Practice of House Officers

2. Introduction: • House officers or interns, are an integral part of the health care team at hospitals in Saudi Arabia. • Interns often find themselves with numerous new responsibilities. This, coupled with little focus on patient safety during study years, may lead to unsafe practices and negative outcomes. • Three important aspects of practice that are considered highly important are: • Hand hygiene • Medication safety • Good handover technique

3. Nosocomial infections are common when not practicing safely and are costly. Up to 1.7 million nosocomial infections occurred in the US in 2002, resulting in 99,000 deaths. • International study by the WHO (14 countries) revealed that 8.7% of patients had hospital-acquired infections. • Another study in 2004 in Taif, KSA revealed that 50% of infections that occurred during admission were nosocomial.

4. The most common route of transmission of nosocomial infections is by direct and indirect contact. • Therefore, proper hand hygiene is the single most effective and simple way to prevent nosocomial infections.

5. Medication errors are a similarly important cause of morbidity and mortality. • A 2011 Saudi study found that 56% of medication orders for pediatric inpatients contained at least one error, with dose errors being the most common type. How to reduce it ? • The use of generic names • Avoiding abbreviations • Electronic order entry • Double-checking medication orders

6. Clinical handover: • Studies show that ineffective handover practices increase adverse events by 3.5 fold, resulting with: • delayed diagnosis • increased length of stay • excessive and unnecessary tests. • Poor handover practices often result from a lack of: • Standardization, • Updated information • Task prioritization • Junior doctors are also often reluctant to request more information when receiving patients.

7. Handover Project:

8. Methods: • The goal is to assess the patient safety related aspects of interns’ medical practice at KAUH. • We developed our own questionnaire, in the form of a subjective self-assessment. • The questionnaire consisted of a biographic portion: • the gender, • place of graduation (KAU vs. non-KAU) • current rotation. 4 parts of questions: • Hand hygiene • Medication safety • Handover practice • Questionnaire validation. Samples collected at KAUH between 28/12/2011 and 31/12/2011.

9. Results: • A total of 66 responses were obtained and analyzed. • 50% (33) were female • 50% (33) were male • 92% (61) were KAU graduates • 8% (5) being non-KAU graduates

10. Questionnaire Sixth Year Patient Safety Project: Intern Practice and Patient Safety Gender: [ ]M [ ] F [ ] KAU graduate Rotation:_________ [ ] Non- KAU graduate Part 1: Hand Hygiene 1. Do you wash your hands [with soap and water or alcohol] before examining each patient? [Choose one answer] [ ] All the time. [ ] Most of the time. [ ] Sometimes. [ ] Rarely. [ ] Never 2. Do you wash your hands [with soap and water or alcohol] after examining each patient? [Choose one answer] [ ] All the time. [ ] Most of the time. [ ] Sometimes. [ ] Rarely. [ ] Never 3. In general, what factors do you think decrease adherence to hand hygiene guidelines at KAUH? [Check all that apply] [ ] Lack of awareness. [ ] Sinks/Dispensers poorly located. [ ] Empty dispensers. [ ] Heavy workloads. [ ] Other: _________________________________________________________________________________

11. Part 2: Medication Safety: 4. When I write drug orders I use generic names: [Choose one answer] [ ] All the time. [ ] Most of the time. [ ] Sometimes. [ ] Rarely. [ ] Never. 5. When I write drug orders I write the full drug name: [Choose one answer] [ ] All the time. [ ] Most of the time. [ ] Sometimes. [ ] Rarely. [ ] Never. 6. Have you made any errors regarding medications since starting your internship? [ ] Yes [ ] No 7. If you answered yes to the previous question, what factors do you think contributed to these errors? [Check all that apply] [ ] Poor handwriting [ ] Confusion between similarly named drugs [ ] Use of trade names [ ] Use of unconventional abbreviations [ ] Fatigue [ ] Heavy workload [ ] Other: _________________________________________________________________________________

12. Part 3: Patient Handovers 8. What is the method you most often use for patient handovers? [Choose one answer] [ ] Written. [ ] Face-to-face, bedside [ ] Face-to-face, non-bedside [ ] Phone call [ ] Other: 9. What problems do you encounter with patient handovers? [Check all that apply] [ ] Lack of standardized method [ ] Poor communication [ ] Missing/old information [ ] Lack of task prioritization [ ] Other:_______________________________________ Part 4: Questionnaire Evaluation: 10. What problems did you encounter with this questionnaire, if any: [Check all that apply] [ ] Lack of clarity. [ ] Not relevant to our practice. [ ] Too long. [ ] None. [ ] Other:_______________________________ 11. Do you have any suggestions? ______________________________________________

13. Results: Question 1 Do you wash your hands [with soap and water or alcohol] before examining each patient?

14. Question 2: Do you wash your hands [with soap and water or alcohol] after examining each patient?

15. Question 3: In general, what factors do you think decrease adherence to hand hygiene guidelines at KAUH?

16. Question 4: When I write drug orders I use generic names:

17. Question 5: When I write drug orders I write the full drug name:

18. Question 6: Have you made any errors regarding medications since starting your internship?

19. Question 7: If you answered yes to the previous question, what factors do you think contributed to these errors? [Check all that apply]

20. Question 8: What is the method you most often use for patient handovers?

21. Question 9: What problems do you encounter with patient handovers? [Check all that apply]

22. Question 10: What problems did you encounter with this questionnaire, if any: [Check all that apply]

23. Discussion: • Our results showed that compliance with hand washing guidelines was better after examining patients compared to before patient examination. • 72% reported washing hands before examinations all or most of the time • 86% reporting hand washing after patient examinations all or most of the time. • This is in contrast to a 2009 study by Schechter, et al, which found that 35% of interns did not wash their hands prior to examining patients, and 95% did not wash their hands afterwards.

24. Heavy workloads and lack of awareness were the most frequently cited factors that decrease compliance with hand hygiene guidelines. • Females cited “heavy workloads” twice as often as their male colleagues, • Males cited “lack of awareness” more than twice as often as females.

25. Overuse of trade names and abbreviations remains a problem at KAUH including interns. • Medication related errors are also frequent; 44% • Males were more likely to report making errors than females (51% vs 36%). • The most commonly cited contributing factor is confusion between similarly named drugs, followed by heavy workload. • This also highlights the importance of double-checking drug orders, as this can uncover up to 95% of medication errors.

26. The vast majority of respondents reported using direct modes of communication during patient handovers. • However, a lack of standardized methods for patient handovers was the most commonly cited problem when handing over patients. • It is vital to instruct junior physicians to use directcommunication methods when handing over patients.

27. Limitation: • Lack of clarity in our questionnaire, was reported by (13%) of the responders. • The nature of self-reported assessmentsopens up the possibility of cognitive bias. • Finally, the busy schedule of most interns may have interfered with their ability to adequately assess each question.

28. References: Klevens RM, Edwards JR, Richards CL, et al. "Estimating healthcare-associated infections in US hospitals." Public Health Rep 122.2 (2007): 160-6. RD, Scott. The direct medical costs of healthcare-associated infections in US hospitals and the benefits of prevention. 2008. <http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf>. E., Tikhomirov. "WHO programme for the control of hospital infections." Chemioterapia 6.3 (1987): 148-51. Abdel-Fattah, Moataz M. "Surveillance of nosocomial infections at a Saudi Arabian military hospital for a one-year period." Ger Med Sci 3.6 (2005). Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee. 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings. < http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf>.

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30. Thank you