Patient Safety: How You Can Prevent Medical Errors

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

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…” Help People---Stomp Out Disease First Do No Harm

3. The Institute of Medicine: 44,000 – 98,000 preventable adverse events yearly Exceeds those who die from highway accidents, breast cancer, and aids

4. Medical Care…Then and Now

5. First Do No Harm Safety of patients is our priority ….and we could be doing a better job!

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 Human Glitch Flawed Systems Patient Harm James Reason, Human Error

8. What Type of Human Glitches Cause Harm? JCAHO Sentinel Event Statistics, 2004

9. JCAHO: Sentinel Event Statistics, 2004

10. JCAHO Sentinel Event Statistics, 2004

11. What is Our Goal? Patient Safety • Freedom from accidental injury due to medical care, or medical errors

12. So What Can You Do About It? • Use Communication Tools • Be Conscientious of Signouts • If you see something wrong, tell someone It’s Not Rocket Science…

13. Communication Tools • Read back for all verbal orders • Standardization for order sets • OR Time-Outs • SBAR So 1 order moo-shoo, fried rice…and what kind of milk? Can I have an order of moo-shoo pork, fried rice, and milk?

14. Case Presentation: Edith presents with SOB TimeLine 12AM 1AM 2AM 3AM 4AM 5AM 6AM 7AM 8AM Shortness of Breath Sent for CXR & Labs Admit Settled on ward Edith in ED ED Resident Shift Change ED Resident Night Float Resident Medicine ward Medicine Resident

15. Day 1 TimeLine 10AM 2PM 6PM 10PM 2AM 6AM 10AM 2 PM 6PM Decompen-sates Edith in ICU Edith in ICU Edith Stable Edith Stable Transfer to ICU On Call Medicine Resident Resident 5 goes to clinic Cross coverage Resident Resident returns Resident goes home Day Float Resident Day Float goes home On call intern

16. Day 2 TimeLine 10PM 2PM 6PM 10PM 2AM 6AM 8AM 12 PM 4PM Edith in ICU Shortness of Breath/ Intubated Intubated & Stable Extubated On Call intern sign out Intern Night Float Resident Returns Resident continues

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.” Total Residents in Charge of Care: 9 Total Sign-outs: 10

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 4000 Handoffs Daily, 1.5 Million Handoffs per Year

19. Housestaff Experiences Perceptions Impacts • “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 Vidyarthi, JGIM, 2006;Kitch, Jt Comm J Qual Patient Safe,2008; Irani, Surgery, 2005

20. Discontinuity and Patient Harm • Most significant risk for an adverse event: • cross-covering MD Petersen, L. A. et. al. Ann Intern Med 1994;121:866-872

21. University Health Consortium Position Papers IM, ER, Surgery, Hospital Medicine Society of Hospital Medicine Joint Commission Effective Handoff: Signout must include Written Verbal + Handoff Best Practices Best Practice Guidelines Do it…well Standardize UHC,2006; Solet, Academic Med, 2005; Kemp, Arch Surg, 2008; Vidyarthi, JHM 2006; Arora, JHM pending; Joint Commission, 2009

24. Communication Channels www.agilemodeling.com/essays/communication.htm

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

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

29. Case Review: To Fix the System… Root Cause Analysis Case Review-Peer Review • 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

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… Safety Quality • 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

32. And on the Quality Front… McGlynn, E. A. et al. N Engl J Med 2003

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 $400 each/Total $1200

36. Safety and Quality are About Systems Think of your doctors and nurses as actors in a grand play. Sure, the play is different when King Lear is played by Sir Laurence Olivier or Robin Williams. But Lear dies in both stagings. Internal Bleeding, Wachter and Shojania

37. Safety and Quality are About Systems Think of your doctors and nurses as actors in a grand play. Sure, the play is different when King Lear is played by Sir Laurence Olivier or Robin Williams. But Lear dies in both stagings. If we want the patient to live, we must change the script! Internal Bleeding, Wachter and Shojania

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 First Do No Harm Help People---Stomp Out Disease

39. THANKS