When Bad Things Happen to Good Doctors: Patient Safety, Medical Errors, and You

1. When Bad Things Happen to Good Doctors: Patient Safety, Medical Errors, and You Tricia Pil, MD University of Pittsburgh Health Sciences August 26, 2010

2. Presentation Overview • The scope of medical error • Why medical errors happen • Practicing safely in an unsafe system • Caring for patients after an adverse event • Caring for clinicians after an adverse event • Acknowledgements and resources

3. Primum non nocere First Do No Harm and yet…

4. The Scope of Medical Error Every year in the U.S.: • 44,000-98,000 people die in hospitals due to medical error. • Nearly 2 million patients acquire nosocomial infections. • Medication-related errors cause an estimated 7,000 deaths. • More than 2/3 of adverse events are preventable, and 28% are due to negligence of a health care professional. Photo courtesy of IHI Open School for Health Professions, 2010 Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. Brennan T, Leape L, Laird N, et. al. Incidence of Adverse Events and Negligence in Hospitalized Patients. NEJM 1991; 324(6): 370-376.

5. Why Do Medical Errors Happen? • Diagnosing and treating patients is incredibly complex • Practitioners not adequately trained or prepared to deliver care as a well-integrated team • Flawed processes or systems of care • Weak culture of safety in an organization • Highly technical equipment • Time pressures • Fatigue • Many caregivers and multiple “handoffs” • Limited resources • Highly acute or emergent illness and injury • Environment full of distractions • Variable patient volume • Inconsistency or disagreement over what constitutes “best practice” • Difficulty keeping up with “the latest” in evidence-based medicine • Fear of medicolegal liability impedes reporting and learning from errors • Little incentive from insurance companies to reduce errors or reward safety and quality

6. Reason’s Swiss Cheese Model • Quality Improvement means: • Every system is perfectly designed to get the results it gets. • Making it easy for people to do things right and hard to do things wrong. Reason, J. Human Error. New York, NY: Cambridge University Press, 1990.

7. Practicing Safely in an Unsafe System Five critical behaviors that YOU can do to improve safety: • Follow written safety protocols • Speak up when you have concerns • Communicate clearly • Don’t let yourself or others get careless • Take care of yourself

8. Follow Written Safety Protocols http://www.tubechop.com/watch/35295

9. Speak Up When You Have Concerns • Identify and report issues with policies and procedures • Report unsafe working conditions, near misses, and adverse events • Verbalize concerns

10. Adverse Event Reporting at UPMC

11. Other Reporting Options www.jointcommission.org www.health.state.pa.us www.dos.state.pa.us

12. Communicate Clearly

13. Communicate Clearly • Listen to your patient • Check for understanding • Use SBAR • Situation • Background • Assessment • Recommendation • Provide read backs

14. Don’t Let Yourself or Others Get Careless June 2009: At an oil drilling rig, company engineers express concerns about well casings that violate their own safety and design guidelines. Yet they proceed. March 2010: The rig is hit by several gas “kicks” and the blowout preventer leaks fluids at least three times. Still, federal inspectors “pass” the rig. April 1, 2010, internal memo: Use of cement “against our best practices.” Quality test skipped. April 18, 2010, internal memo: Improperly centered casings likely to cause “severe” gas flow problem. April 20, 2010: The Deepwater Horizon drilling rig explodes, killing 11, injuring 17, and causing untold damage to wildlife, coastlines, and local economies. It is the largest marine oil spill in the history of the petroleum industry. Urbina, Ian. “In Gulf, It Was Unclear Who Was in Charge of Oil Rig.” New York Times 5 June 2010.

15. Take Care of Yourself Be aware of your own physical and emotional limitations, including: • Post-call fatigue • Illness • Stress “Physician, Heal Thyself”?

16. Revisiting Babel: The Clinician Perspective Patient:We are moved to the postpartum floor. Seven hours later, I suddenly feel weak, dizzy and nauseated. I say, "Somebody help me, I don't feel well." The next minute, I'm hemorrhaging. There is blood spurting everywhere, clots the size of frying pans. I think I am going to die. Panicky nurses and residents crowd the room. The crash cart is wheeled in, my baby is wheeled out. My husband is shouting, "Somebody get Doctor B!" I am being stuck everywhere for an IV. Someone says that there will be a "procedure," and then my underwear is cut off, injections slammed into my buttocks, my legs are forced open and somebody shoves an entire forearm into my uterus and pulls out clots. Three times. I scream and scream and scream. The pain is unbearable, and I feel brutally violated.Chart:7:30 am: Called to see patient passing clots. Passed two medium size clots. Blood pressure 110/67…100/60…90/58. Pulse 88…96. Patient uncomfortable, vomited x 2. Bimanual evacuation lower uterine segment with 3 large clots. Orders: IV, Pitocin IV, Methergine IM, Morphine IM, Zofranprn. Discussed with Doctor B.--InternHospital:Once again, we refer you back to your private physician for a detailed discussion about the hemorrhage you outlined. Pil T. Babel: The Voices of a Medical Trauma. Pulse Magazine. 9 April 2010. Web .20 August 2010.

17. SILENCE

18. What to Say to Patients and Families After an Adverse Event

19. What to Say to Patients and Families After an Adverse Event Tell the patient and family what happened. “I would like to monitor you closely over the next few weeks. “How are you feeling? What other support do you need right now?” “If you have any questions later on, here is the number to reach me directly.” “Let me tell you what happened. We gave you drug X instead of drug Y you were supposed to receive.” “We failed you.” “This shouldn’t have happened.” “We made this error. I apologize.” “I’m sorry this happened. It’s terrible.” “Our systems broke down. We’re going to find out what happened and do everything we can to see to it that it doesn’t happen again.” Take responsibility. Apologize. Explain what will be done to prevent future events. Follow up. When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; March 2006.

20. Full Disclosure—Does It Work? The University of Michigan Health System’s Medical Error Disclosure Program showed: • Monthly rate for new claims: 36% • Monthly rate of malpractice lawsuits: • 50% • Median time to resolve claims: from 16 to 11 months • Mean liability costs: 60% • Average costs for lawsuits: from $406K to $228K Kachalia A, Kaufman S, Boothman JD, et. al. Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. Ann. Intern Med. 2010; 153:213-221.

21. Impact of Medical Error on Healthcare Professionals: “The Second Victim” • Isolation • Shame • Self-doubt • Grief • Guilt • Fear http://www.rmf.harvard.edu/education-interventions/films/healingthehealer/index.aspx “I was now forced to confront my own emotional distress and I realized my complete lack of training in how to manage this situation. In an instant, the years of clinical training, my board certification, and the respect of my colleagues as a competent anesthesiologist had become irrelevant and meaningless. I felt lost and alone.” – Rick van Pelt, MD

22. Barriers to Clinician Support Following Adverse Events • “Perfectionist” educational models • Practice “silos” • Dysfunctional team dynamics • Fear of litigation • “Shame and blame” culture • Productivity pressures

23. Future Vision: Elements of an Effective Clinician Support Program • Has visible commitment from executive and medical leadership • Is widely publicized, easily, and immediately accessible • Offers confidential one-on-one and team peer support • Is written in to adverse event policy and procedures • Provides clear roles for trained responders • Is attentive to individuals involved directly or indirectly in the event • Provides proactive training, education, and outreach • Is partnered closely with risk, safety, and quality departments • Includes periodic follow up Carr S. Disclosure and Apology: What's Missing? Advancing Programs That Support Clinicians. Medically Induced Trauma Support Services; November 2009.

24. Acknowledgements and Resources Tricia Pil, MD University of Pittsburgh Health Sciences tpil@pitt.edu