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The Disruptive Physician Federation of State Physician Health Programs 2010 Annual Meeting

The Disruptive Physician Federation of State Physician Health Programs 2010 Annual Meeting. Doris C. Gundersen, MD Medical Director Colorado Physician Health Program. Sentinel Events. Defined by The Joint Commission as:

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The Disruptive Physician Federation of State Physician Health Programs 2010 Annual Meeting

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  1. The Disruptive PhysicianFederation of State Physician Health Programs2010 Annual Meeting Doris C. Gundersen, MD Medical Director Colorado Physician Health Program

  2. Sentinel Events Defined by The Joint Commission as: “Any unanticipated event in a healthcare setting resulting in death or serious physical injury or psychological injury to a person or persons not related to the natural course of the patient’s illness.”

  3. Examples of Sentinel Events Loss of limb or gross motor function Infant abduction or d/c to wrong family Unexpected death of full term infant Severe neonatal jaundice (bili > 30mg/dl) Surgery on wrong patient or body part

  4. Examples of Sentinel Events Object left in body post operatively Rape in continuous care setting Suicide in a continuous care setting Hemolytic transfusion reaction Radiation to wrong area or 25%> than RX

  5. Sentinel Events Causal Factors are analyzed Systems and processes are reviewed Individual performance not reviewed Root cause analysis performed Action Plan for improvements implemented Accredited organization reports to JC ≤ 45 days

  6. Advantages of Reporting Sentinel Events Contributing to database (track negative trends) Dissemination of information for prevention Joint Commission association serves to reassure the public and demonstrate the priority of patient safety

  7. Joint Commission In its root-cause analysis of sentinel events, the Joint Commission traced 70 percent back to communication failures. We have strived to improve patient care through technology. The human factors are also crucial

  8. Joint Commission, Issue 40July 9, 2008 • Defined Disruptive Behavior as a Sentinel Event • Recognition that disruptive behavior can: • Foster medical errors • Contribute to poor patient satisfaction • Contribute to preventable adverse outcomes • Increase the cost of care (including malpractice) • Lead to turnover/loss of qualified medical staff

  9. Joint Commission • Goal of including Disruptive Behavior as a Sentinel Event: • Reform health care settings to address the problem • There is a history of tolerance and indifference • Promote a culture of safety • Improve the quality of patient care by improving the communication and collaboration of health care teams

  10. Joint Commission Requirements Hospitals establish a formal Code of Conduct Leadership creates a process for reporting, evaluating and managing disruptive behavior

  11. Joint Commission Recommendations Educate all team members about professionalism Hold all team members accountable for modeling desirable behaviors Enforce the code consistently and equitably Nonconfrontational intervention strategies Progressive discipline

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