Physician Basic Safety Training

1. Physician Basic Safety Training Note: This training is based on actual safety events that happened in UC Health facilities. This is not bureaucracy – it matters! There are 20 slides and it will take you 10 minutes to complete – please give safety a few minutes of your time. This course meets Hospital initial physician training requirements for: Blood Borne Pathogen Training General Workplace Safety UC Medical CenterAnnual Review (STAR) National Patient Safety Goals

2. Confirm Identity When Writing Orders (National Patient Safety Goal #1) Case Report: A physician ordered amlodipine, atenolol, and hctz for a patient. The nurse questioned the orders, the doctor confirmed them, and a dose of each was given. The doctor discovered later that he had written these orders on the wrong patient. • Lesson Learned: • Double-check patient identity when writing orders (CPOE, the EMR, and paper). • When someone expresses a concern, listen…. And then take a moment to double-check – they might be wrong but they might just be right also.

3. Keeping Verbal Orders Safe Case Report: A physician gave a verbal order for “5 of vercuronium” during an emergent procedure. The nurse thought she heard “versed” and gave that. When the patient was not paralyzed, the doctor said to “give 5 more”. After the second failed dose, they realized the error and gave the correct medication. • Lesson Learned: • Try not to use verbal orders. • If a verbal order is needed, give a complete order. • Require the nurse to read back and verify what you said. • Confirm aloud that what you heard was correct. • Do this verbal back-and-forth deliberately every time.

4. Never Pre-Sign a Form – It’s Fraud Case Report: This Discharge Summary form was found in a patient's chart – pre-dated and signed before it was completed. Regulatory agencies consider this to be falsification of records and a serious offense. Don’t do it!

5. Be Careful What Information Is Given to Visitors and Relatives (HIPAA) Case Report: A surgeon spoke to family members after a procedure and told them off-hand that the patient’s healing would be a little slower because of his HIV. They had not been aware of the patient’s HIV status previously. • Good privacy habits: • Think about what you are disclosing and always ask visitors to step out of the room before discussing personal information. If the patient says it is OK for them to stay – then you’re OK. • Provide counseling in a private area whenever possible. If not possible, make attempts to protect privacy (e.g. – pull the curtains and talk softly).

6. Medication Reconciliation Is a Physician Responsibility Case Report: An admitting physician listed a patient’s thyroid dose as 25 mcg in his H&P and that is what he ordered for the patient. The patient's correct home dose was 150 mcg. The patient had a tremor and high thyroid tests on admission testing so that the dose was reduced to 12.5 mcg and that is what the patient was sent home on. He was readmitted later with altered mental status and a very low T4 and high TSH. Lessons Learned: Getting meds right when patients come in and go home is really important and a physician responsibility.

7. Checking and Reconciling Allergies Is Everyone’s Responsibility Case Report: After checking office records and asking the patient about allergies, a clinic patient was given an IM dose of ceftriaxone. The patient collapsed from anaphylaxis soon after. Later, it was discovered that he had a previous allergic reaction to ceftriaxone documented in Last Word. • Lessons Learned: Currently, UC Health has multiple data systems which means multiple lists of allergies. Cases like this one are one of the reasons we chose to buy an integrated electronic health record (EPIC). • It is important to check all available sources of allergy information before prescribing medications.

8. Key Things to Know About Heparin Protocols • There are 4 protocols for infusion heparin. • Using protocols reduces errors - use a protocol whenever possible. • Heparin dosing is weight-based up to a point. If a low-dose protocol patient weighs more than 83 kg, use 83 kg rather than their true weight in the protocol.

9. Key Things to Know About Pain Management • Use a pain scale to assess the patient's perception of pain. • A behavioral scale is used for non-responsive patient. • Whenever an order is written for an IV titratible drip for sedation, the physician must indicate the target level of sedation. • If more than one pain medication is ordered for a patient, the physician must provide clear instructions on which medication is to be used first and when to go to the second med.

10. Use Restraints Sparingly – Order and Document Them Correctly When Used • It is a patient right to be free from restraints and seclusion unless needed to protect himself or others. • Less restrictive measures must be considered before ordering restraints. • All restraints require a physician order, initial assessment (why are the being used), and interval reassessment.

11. Fall Prevention (National Patient Safety Goal #9) Case Report:A patient returned from the PACU/OR following surgery. The patient was oriented but slightly confused from the anesthesia. The nurse evaluated him but was called to care for a patient having a seizure. Five minutes later, the nurse was called back by the roommate saying the patient was on the floor. The fall resulted in a complication and return to surgery. All patients are assessed for fall risk at admission and during each shift as required by our fall reduction program. At UCMC, Fall Risk patients wear a yellow bracelet and will be identified by a yellow or red magnet on the door. At WCH, Fall Risk patients are identified by a yellow magnet placed on the door.

12. Universal Protocol / Time Out The challenge is not doing time outs, it's doing them well. Pay Attention! Case Report: A patient had a left pleural effusion. The physician tried a right thoracentesis by mistake. The patient got a pneumothorax. Records showed a checkmark in the box on the procedure note indicating that the team had done a “time out”. Lesson Learned: (1) “Timeouts” are a good safety practice for anything you do that might hurt a patient or is irreversible. (2) This is not about a check mark in the box on the form. The challenge is to be mindful and really pay attention and check.

13. How to Report Safety Problems • Put an incident report into the computer system (On the main SharePoint page, click “Enter an Incident Report” and follow the prompts) • Patient Safety Hotline UC Medical Center: 584-2109 • Anyone wishing to identify a potentially unsafe act, • process, procedure or system can call into the • hotline from any hospital phone line. This can be • used for reporting near misses, or when you are • unsure of the proper channel to report an incident. • Any report may be anonymous.

14. Better Documentation for Quality Remains a Key Priority Case Report: Several years ago, UC Medical Center(and its physicians) were rated as “Worse Than National Average” for pneumonia mortality. When we investigated this we found many documentation and coding problems. A coding improvement initiative was started and now UH is back in the “Same as National Average” range. Lessons Learned: There are a lot of organizations who are “measuring” and reporting our “quality” on the internet using publicly-available claims data and statistical risk models. How our quality appears in such models depends on how well we document what patients really have.

15. Electronic Health Records Downtime Case Report: Our previous system went down on a Sunday morning and stayed down for 14 hours. Some staff were unaware of how to perform normal functions without the computer and had trouble getting lab and x-ray results. As with any computer system, downtimes are a reality. This can happen with EPIC too. Each unit has a “Downtime Packet” with detailed plans on what to do and a computer with running records of key information such as patient medications. If a downtime occurs, consult the Downtime Packet, identify the downtime computer, and contact radiology and the lab by phone for needed test results.

16. Fire Safety in the Operating Room Case Report: A patient was undergoing surgery and a decision was made to enter the chest intraoperatively and Chloroprep (alcohol and chlorhexidine) was applied to the skin by a member of the surgical team. A Bovie was used to cauterize bleeders. A fire occurred at the incision and involved a lap sponge that was extinguished on the floor. Every MD needs to be aware of the flammability risks associated with medical solutions, gases, surgical materials, and electrocautery devices.

17. Fire Safety in the Operating Room Fire can occur when an ignition source, oxidizer and fuel are combined. These three elements constitute the Fire Triangle and are abundant in the Operating Room.

18. Reducing Blood-Borne Pathogen Exposures Case Report: A PCSA picked up a plastic bag to dispose of it. Someone had placed bloody fluid in the bag and a splash occurred into the PCSA’s eyes and mouth from a hole in the bag caused by improperly disposed sharps. An OSHA inspection followed and the hospital received an OSHA fine of $26,500. Please dispose of blood and sharps correctly. Additional Advice: Make sure you wear Personal Protective Equipment (PPE) – gloves, gowns, masks, eye protection, surgical caps, hoods and shoe covers where necessary. Place blood and other infectious waste in Red biohazard containers.

19. Let’s Reduce Sharps Injuries In 2012 there were 150 sharps-related injuries at UCMC, and 17 sharps-related injuries at WCH. 65 of the injuries were to residents and fellows. • Here is what to do to reduce your risk of sharps injuries • Place sharps carefully in proper containers. • Do not overfill sharps disposal containers. Containers should be replaced when 3/4 full. • Be sure nothing sticks or spills out of the container. • Dispose of sharps disposal containers in bio-hazardous trash container, NOT in regular trash. • Clean reusable sharps carefully. • Put sharps away in their proper places. • Do not recap or bend needles.

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