Lessons Learned on Patient Safety

1. Lessons Learned on Patient Safety FCC of MHRI

2. The Present Culture • 12 minutes for every encounter, 18 seconds elapse before 1st interruption and 75% leave with unanswered questions. • Medication safety: 25% of patients in a year had Adverse Drug Reaction • 11% preventable • 3% were potential to harm and 95% of these would have been prevented

3. Levels of maturity with respect to a safety culture E. Risk management is an integral part of everything that we do D. We are always on the alert for risks that might emerge C. We have systems in place to manage all identified risks B. We do something when we have an incident A. Why waste our time on safety? PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE

4. Safety Minefields • Transitions of Care • 20% after discharge had a significant result: Med errors lead the pack • Only 25% mentioned pending tests F/U • Missed or Delayed Diagnoses • Cognitive Errors: Reliance on Memory • Test tracking, Ordering of tests and F/U • Referrals: timeliness and clarity

5. Medication Pitfalls • Survey says: 200,000 Rxs written only 72% were filled • Adherence and Medication reconciliation • Ask-Educate-Ask

6. Take home Points • Transitions of Care • Template for first visit after discharge • Bullet points on Discharge summary of most important topics, pending tests, labs and procedures done • Must be available at first visit: only 12% are available • Medication Reconcilliation at every step

7. Test Tracking • No News is not good news! • How does the patient prefer to be contacted about results: phone, e-mail, snail mail • If you do not hear from the office in X amount of time after the study should take the initiative to contact the office. • Order entry will help not to lose tests • Tickler systems essential for tests and referrals • Standardize process and procedures

8. Culture of Safety • Walk Rounds • Senior level engaging and NON-punitive • Safety Huddles: Huddles to Shape the Day and regular huddles • Debriefings at the End of the Day and after any event. • Event Reports: Primary Care M & M

9. Culture of Safety • Need safe and supportive Accountability • Need Resources • Clinical Decision Support at P.O.C.: Algorithms • Big hitters: Cancer prevention,tests and follow up • Communication in the office, at the hospital, with the specialists and the administration • Consistency, Teamwork, Safe environment

10. Tools • Trigger Tools • Ambulatory Safety Survey: ARQHC • MGMA: Patient Safety Score • Donabedian: Structure + Process = Outcome • MaPSaF safety culture assessment

11. Trigger Tool

12. Primary Care Trigger Tool

13. London Protocol

14. Tool Benefits

15. Individual Benefits

16. Framework Document

17. Next steps • Pre Huddles and post Huddles • Trigger Tool Use • Better tracking of tests, reports, reminders • Transparent Walk Rounds • Standardization for test notification, • Standardization for using EMR medication reconcilliation • Keep up the transition of care excellence • Decision support tools in the EMR • First visit post hospitalization template • Patient surveys and practice survey tools