Patient Safety 101 for Neurologists

1. Patient Safety 101 for Neurologists

2. Overview • The history of patient safety • Situations that lead to medical errors • Case studies • How do we avoid medical errors

3. Patient Safety: The History • Hippocrates – “Primum Non Nocere” • Beneficence • Non-malfeasance • Florence Nightingale • “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

4. The History of Patient Safety • Post-World War II • Modern advances in the ability of medicine to help were accompanied by a corresponding increase in the ability to do harm • Studies of the impact of medical errors began to appear in late 1980s to early 1990s • Harvard Medical Practice Study • Reviewed >30,000 charts from randomly selected patients in acute and non-acute hospitals in New York • 3.6% of hospitalized patients experienced adverse events resulting in harm • 70% of these events resulted in disability lasting less than 6 months, 13.6% resulted in death, 2.7% permanent disability

5. The History of Patient Safety • Quality of Australian Health Care Study in 1995 • Placed greater emphasis on quality of care than negligence, i.e., could the adverse event be prevented? • Reviewed >14,000 charts from 28 hospitals • 16.6% of hospitalized patients experienced adverse events • 77.1% of those had disability lasting less 12 months • 13.7% with permanent disability • 4.9% ended in death • 51% of the adverse events were considered preventable

6. The History of Patient Safety • In early 1995 an epidemic of errors erupted • Michigan --a surgeon performing a mastectomy on a 69-year-old patient removed the wrong breast • New York--a woman died when a doctor mistook her dialysis catheter for a feeding tube and ordered food to be pumped into her abdomen • Tampa --a 51-year-old diabetic had the wrong foot amputated and a 73-year-old retired electrician died when a therapist mistakenly disconnected his ventilator

7. The History of Patient Safety • Institute of Medicine Report “To Err is Human” • Landmark paper published in 1999 • Estimated incidence of patients who die in hospital due to preventable medical error • Was the springboard for emphasis on patient safety, quality improvement initiatives, and ultimately pay for performance

8. What is Medical Error? • Definition according to IOM • Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim • Examples: • adverse drug events • surgical injuries and wrong-site surgery • restraint-related injuries or death • falls • pressure ulcers

9. The History of Patient Safety: IOM report “To Err is Human” • Medical error is the 8th leading cause of death in the US. • Medical errors cause 98,000 deaths per year. • More people die from medical error than from breast cancer, HIV, or MVAs.

10. Types of Error • Diagnostic • Failure to order appropriate test • Delay in diagnosis • Failure to act on results or monitoring • Treatment • Error in the performance of an operation, procedure, or test • Error in administering the treatment • Error in the dose or method of using a drug • Preventative • Failure to provide appropriate monitoring or follow-up • Failure to provide prophylactic treatment • Other • Failure of communication • Equipment failure • Other system failure

11. USA TODAYThursday, June 28, 2001 Hospital mistakes must be disclosed Accreditation at risk if patients aren’t told By Robert Davis Hospitals must now tell patients and their families when they have been hurt by a medical error, according to nationwide standards that take effect Sunday. The standards by the nation’s leading health care accrediting agency are the first to hold hospitals accountable for a higher level of patient safety. …

12. How Unsafe is Healthcare?? Deaths per 100 million hours • Being pregnant 1 • Traveling by train 5 • Working at home 8 • Working in agriculture 10 • Driving 50 • Working in construction 67 • Being hospitalized 2000

13. Cost of Medical Error • Estimated direct cost of medical error in US $17 billion • Preventable adverse events to Medicare patients estimated to cost in excess of $880 million annually • A study from 2008 revealed overall cost of medical error in the US to be >$19.5 billion • Total cost per error approx. $13,000 • >2500 avoidable deaths • >10 million days of lost productivity at work, costing $1.1 billion in short-term disability claims

14. Cost of Most Common Medical Errors

15. Why is Healthcare Prone to Error? • Multiple and varied interactions with technology • Many individuals involved in care • Multiple hand-offs • High acuity of illness • Distracting work environment • Rapid, time-pressured decisions • High volume, unpredictable patient flow • Multiple step processes

16. Why is Patient Safety Important to Me? • It can save lives • It can make YOU a better physician • It is part of every hospital plan – no matter where you work • Focused programs are required by the Joint Commission • It is a required part of resident education curriculum by the ACGME and RRC

17. How Does This Affect Neurology? • Many patient groups at risk • Stroke patients with many comorbid illnesses • Potential for drug interactions • High risk for falls • Seizure patients with poor compliance or complex regimens • Parkinson’s patients and dementia patients • Significant cognitive impairment may result in medication error • Physical disabilities may increase risk of falls and injury

18. Of the 300 neurologic lawsuits requiring a pay out in 2004, most common diagnoses: • Disc disorder • Stroke • Headaches/migraine • Seizure • Cancer • Meningitis • Paralysis • Aneurysm

19. National Academy of Science’s Institute of Medicine (IOM) • In 2001, the IOM laid out six dimensions of quality for health care. • According to the IOM, health care should be • Safe • Effective • Patient-centered • Timely • Efficient • Equitable

20. Patient Safety and Quality Improvement Act of 2005 • Signed into Law 7/29/05 • Nationwide Goals • “To encourage the voluntary reporting of medical errors” • Report to “Certified Patient Safety Organizations” • Many providers fear repercussions • Act provides federal legal privilege and confidentiality protection

21. Location of Patient Safety Organizations by State

22. Joint Commission Goals • Improve the accuracy of patient identification • “NEVER” events • Improve the effectiveness of communication among caregivers • Improve the safety of using medications • Reduce the likelihood of patient harm associated with the use of anticoagulation therapy • Reduce the risk of health care-associated infections

23. Joint Commission Goals • Accurately and completely reconcile medications across the continuum of care • Reduce the risk of patient harm resulting from falls • Encourage patients’ active involvement in their own care as a patient safety strategy • Recognize and respond to changes in a patient’s condition

24. Crossing the Quality Chasm– IOM report IOM was supposed to be balanced “…to strike a balance between regulatory and market-based initiatives, and between the roles of professionals and organizations” But it was compliance-heavy “…to create sufficient pressure to make errors so costly in terms of ability to conduct business in the marketplace, market share and reputation that the organization must take action”

25. IOM Stakeholders Providers Implement tools that support clinical decision making and prepare for new reporting requirements. JCAHO Establish disease -specific care performance indicators and mandatory reporting for accreditation High quality SAFE patient care Payors Provide incentives to providers that use tools to increase safety and can demonstrate performance Government Monitor provider organizations through mandatory and voluntary reporting Employers Provide incentives to providers that use tools to increase safety.

26. “Traditional” Patient Safety Honored traditional teaching Blame… Shame… Denial… Errors are caused by… Time-honored solutions to error? Anger… Shoot the messenger… Work harder…Try harder… Blame the system…

27. “Culture” The system of shared beliefs, values, customs, behaviors, and artifacts that the members of that society use to cope with their world and one another, AND … that are transmitted from generation to generation through learning.

28. “Culture of Safety” • Acknowledges high-risk, error-prone nature of modern health care • Shared acceptance of responsibility for risk reduction • Encourages open communication about safety concerns in non-punitiveenvironment

29. “Culture of Safety” • Facilitates reporting of errors and safety concerns • Learns from errors and redesigns safer systems • Ensures that organizational processes, goals, and rewards are aligned with improving patient safety

30. Most Common things that can result in harm to patients

31. #1 MEDICATION ERRORS

32. 1. Medication Errors • Occur frequently in hospitals • Approximately 2% of admissions experienced preventable Adverse Drug Event (ADE) • Estimated increased cost $5000 per patient • ADEs cost about $5.6 million per hospital annually • Average cost per ADE in tertiary hospital $3244 with increased length of stay (LOS) of 2.2 days • Average cost per ADE in community hospital $3420 and increased LOS of 3.1 days

33. Medication Errors • Most common medications associated with harm • Anticoagulants • Antidepressants • Antipsychotic medications • Cardiovascular drugs • Analgesics

34. Predictors of ADEs • Cannot solely be predicted based on patient factors or drug types • Some associated risks: • Older age • Polypharmacy • Severity of illness

35. Medication Errors: What can you do to reduce error or potential harm? • Check your orders for accuracy of dosing • Check medication interactions • Ask specifically about herbals and OTC products • Check medication side effects and ask the patient about these on subsequent visits • Check to see that the patient is receiving the medication as prescribed • Encourage patients to bring in written lists • Use EHR

36. #2 POOR COMMUNICATION

37. 2. Poor Communication • In an average 4-day hospital stay, a single patient may encounter up to 50 different hospital employees • More than 1/5 of patients reported hospital system problems • Staff providing conflicting information • Not clear who the physician responsible for their care is

38. Poor Communication • With ineffective communication, great potential for harm • Lack of critical information • Misinterpretation of information • Overlooked change in status • Unclear orders over the phone • Communication errors identified as the root cause of sentinel (“Never”) events reported to the Joint Commission from 1995 to 2004

39. Barriers to Effective Communication • Hierarchical differences • Inter-professional and intra-professional rivalries • The health literacy of the patient • Differences in language and jargon • Cultural differences • Generational differences

40. Barriers to Effective Communication • Despite your best efforts to communicate and your belief that your have communicated effectively, more patients than you may realize don’t understand what you think they understand. • Rarely will patients reveal limitations in their understanding because they are embarrassed to do so.

41. Barriers to Effective Communication • Health Literacy - Factors affecting patients’ ability to understand • Ability to read • Ability to understand English • Ability to understand medical “lingo” • Cultural / ethnic views of cause and treatment of disease • Complexities of health care system

42. What can we do to improve communication within the health care team? • Ensure that the information is conveyed between staff members at shift changes. • Written sign out including diagnosis, clinical status of patient, pending results, key test results, allergies, CODE status, and “what to do if…” • If possible, bring the nurse into the room to demonstrate the current findings and specific things that you want to be notified about. • Document the teaching and follow-up. • ASSUME NOTHING!

43. What can we do to promote effective communication with our patients? • Speak in plain everyday terms– avoid medical jargon • Use teach-back methods • When possible utilize pictures or diagrams • Provide written information or handouts • Make every attempt to use a medical translator for those patients who are non-English speakers

44. 3. Infection Resulting from Lines and Tubes • Don’t use a Foley catheter unless it is absolutely necessary. • Lines should be dated and checked daily • Lines should be removed as early as possible, and if there is ANY sign of infection As of 2009, CMS and some insurance companies will not pay for infections that develop once a patient is in the hospital

45. 4. The Patient is Not Sufficiently Monitored • Patients may need frequent vitals monitoring, telemetry, serial lab testing depending on their condition • No one will fault you for being “overly cautious”

46. 5. Handwriting • Errors in misinterpretation of written orders account for a large percentage of inpatient mistakes. • Avoid use of trailing zeros • Use 5mg not 5.0mg • Use leading zeros • 0.5mg • Standardized order sets are used to help decrease orders of OMISSION. • However may increase orders of COMMISSION due to duplication of tests or inappropriate medications/tests • Use of electronic health record systems can reduce errors caused by handwriting

47. 6. The Diagnosis is Not Clear • A wrong diagnosis is made because of failure to order the appropriate test • Always evaluate for life-threatening processes that require immediate attention (stroke, myocardial ischemia, pulmonary embolism, intracranial hemorrhage) as appropriate • Review all test results in a timely fashion to ensure that patients are treated appropriately • Who will notify the patient about their test results? How will they be notified?

48. 7. New Information is Ignored • Lab results in clinic resulted but not reviewed or patient not notified of result • Additional history from patient or family • A patient admitted for one thing may develop a new problem while hospitalized • (e.g., patient with a stroke develops an MI)

49. 8. The Patient Who Needs Frequent Blood Monitoring: Diabetes and Anticoagulation • Insulin dosing errors in patients who are not eating • Glucose fluctuations in patients who have infections/stress of illness • Increased risk for bleed in anticoagulated patients • Interactions with other medications • Ex. Many drugs interact with warfarin and may cause INR to increase or decrease • Ex. Antibiotics may interact with and alter levels of anti-epileptic drugs

50. And last but not least. . .