Four Actions The Hospitalist’s Role in Patient Safety

1. Four ActionsThe Hospitalist’s Role in Patient Safety Mark B. Reid, MD Division of Hospital Medicine Denver Health Medical Center University of Colorado: GIM TMC February 17, 2009 Denver VA Hospital

2. To Err is Human: 1999 The flawed assumptions Safety results from complexity Errors are caused by bad people This problem will be easy to fix

3. What has Worked? Regulation: JCAHO Reporting Teamwork Training IT The End of the Beginning: Patient Safety Eight Years After the IOM Report on Medical Errors. Robert M. Wachter, MD, 12th Annual Management of the Hospitalized Patient, San Francisco, CA October 23, 2008

4. Learning Objectives • Know when to wash your hands • 2. Know who to call when an error occurs • 3. Name one intimidating behavior • 4. Name a common CPOE error

5. ACTIONS 1. Do JCAHO2. Report errors3. Be available4. Beware computer errors

6. 1. When rounding on your patients, you foam or wash your hands: A) neverB) before each patientC) after each patientD) whenever someone is watching E) before and after each patient

7. 1. When rounding on your patients, you foam or wash your hands: A) neverB) before each patientC) after each patientD) whenever someone is watchingE) before and after each patient

8. What has Worked? Regulation: JCAHO = rules Reporting Teamwork Training IT

9. Hand Hygiene Donskey and Eckstein 360 (3): e3, Figure 1 January 15, 2009 Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16)

10. # Washes ≥ [# Patients] + 1

11. P4 P5 Practical Script for Hand Hygiene(hand washes are green arrows) Check labs P1 P2 P3 Time Answer phone

13. Action 1 Do JCAHO National Patient Safety Goals: 2009 Correctly identify patients Read back telephone orders “Do not use” abbreviations Critical values Standardized “hand-offs” Look-alike/sound-alike drugs Wash your hands Reconcile medications @ admit and D/C Identify patients at risk for suicide Mark site/time out

14. 2. A patient is transferred to the floor from the MICU after a Tylenol overdose. What special step(s) should you take?A) speak directly to the psychiatry consultantB) confirm that patient has a mental health holdC) assign patient to a sitter roomD) check his bagE) all of the above

15. 2. A patient is transferred to the floor from the MICU after a Tylenol overdose. What special step(s) should you take?A) speak directly to the psychiatry consultantB) confirm that patient has a mental health holdC) assign patient to a sitter roomD) check his bagE) all of the above

16. What has Worked? Regulation: JCAHO = rules Reporting Teamwork Training IT

17. The Promise of Error Reporting:Safety in Air Travel

18. Joint Commission:National Patient Safety Goals

19. JCAHO Root Cause Analysis • Hospitals obliged to report events to JCAHO • 42 reports covering “the worst” errors: PCA by proxy, delays in treatment, prevention of ventilator associated death • Example: 675 inpatient suicides reported as sentinel events • Sentinel Event Alert: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/

20. JCAHO Root Cause Analysis:Inpatient Suicide • Incomplete suicide risk assessment at intake • Failure to identify a contraband • Incomplete communication among caregivers. • Assignment of the patient to an inappropriate unit or location

21. The case of the pills in the bag

22. Action 2 Report ErrorsCall Risk Management for “Never Events” Wrong side/site surgeryAir embolismPatient suicideDeath from medication errorDeath from hypoglycemia (<60)Stage 3 or 4 pressure ulcerDeath or severe disability from a fall National Quality Forum Serious Reportable Events in Healthcare 2006 Update

23. 3. A nurse tells you he noticed a patient was unsteady on her feet. The way you respond to this information could save another patient’s life.A) yesB) no

24. 3. A nurse tells you he noticed a patient was unsteady on her feet. The way you respond to this information could save another patient’s life.A) yesB) no

25. What has Worked? Regulation: JCAHO = rules Reporting Teamwork Training IT

26. Crashing Flight Simulators

27. JCAHO

28. Behaviors that Undermine a Culture of Safety Intimidating and disruptive behaviors can foster medical errors Staff within institutions often perceive that powerful, revenue-generating physicians are “let off the hook” A few commit many but many commit a few http://www.jointcommission.org/SentinelEvents/SentinelEventsAlert/sea_40.htm

29. Are You an Intimidator? • Reluctance or refusal to answer questions, return phone calls or pages • Use of condescending language or voice intonation • Impatience with questions • Verbal outbursts or physical threats

30. TEAMWORK Sutker, James Baylor Medical Grand Rounds, 7/17/2007

31. The Correct Response to the Nurse “Thanks for letting me know. That is very important information. You should always feel free to tell me when you notice anything.”

32. Action 3 Be Available Listen and respect staff opinionsBe approachable and availableDon’t be an intimidator

33. 4. Do computers increase safety?A) yesB) no

34. 4. Do computers increase safety?A) yesB) no

35. What has Worked? Regulation: JCAHO = rules Reporting Teamwork Training IT

36. New Errors in CPOE

37. New Errors in CPOE • Wrong patient selected • Loss of chart personality • Warning desensitization • Order set ignorance Sutker, James Baylor Medical Grand Rounds, 7/17/2007

38. Action 4 Beware Computer Errors 1. Is this the right patient?2. Look up drug doses, especially for infrequently used medicines3. Be redundant—talk to a human being!

39. Learning Objectives Did you learn anything? • Know when to wash your hands • 2. Know who to call when an error occurs • 3. Name one intimidating behavior • 4. Name a common CPOE error

40. ACTIONS 1. Do JCAHO2. Report errors3. Be available4. Beware computer errors

41. Questions?