Prevention of Medical Errors

1. Prevention of Medical Errors KIMBERLY REED, O.D., FAAO No financial disclosures

2. Welcome • Goals • Fulfill obligation as licensed optometrists • Promote wellness as individuals • Course Overview and Format • Medical Errors • Statistics • Types/definitions • Hospital based errors • Medication errors • Root cause analysis and prevention • EMR/EHR • Help or hindrance?

3. Florida’s requirements • Florida Rule 64B13-5.001 (8) • Last updated 2006 • “Must include a study of root-cause analysis, error reduction and prevention, and patient safety”

4. Errors made by our colleagues • Dilated with 1% tropicamide? • Samples of artificial tears? • Expired samples

5. IOM, 1999: To Err Is Human: Building a Safer Health System • Between 44,000 and 98,000 people die every year due to preventable errors in U.S. hospitals

6. Responses to IOM Report • CE requirements • Mandatory or voluntary systems for reporting medical errors (National Quality Forum, 2007) • Joint Commission (JCAHO) requires healthcare institutions to analyze errors using root cause analysis

7. Responses to IOM Report • Patient Safety and Quality Improvement Act (database) • Centers for Medicare and Medicaid Services – will not reimburse hospitals for treatment of 8 preventable errors • Medicaid, Aetna, BCBS, etc. following suit

8. Healthcare Associated Infections (HAI) • 100,000 deaths per year • Leading complication of hospital care

9. Agency for Healthcare Research and Quality • AHRQ.GOV • $50 million annually to research patient safety • Grants ranging from $400 – 1.2M to study HAI prevention

11. Postoperative sepsis per 1000 elective-surgery

12. Based on income….postoperative sepsis • Lowest income • Highest income • Self pay • Medicaid

13. Children who needed care right away who didn’t get it

14. White • Hispanic • Black • English speaking • Non-English speaking

15. Responses to IOM report • President Clinton tried to implement mandatory reporting system for medical errors • Lobbied against by AMA and AHA • 81 million dollars • “If medical errors and infections were better tracked, they would easily top the list {of cause of death in the U.S.}. In fact, a visit to your doctor or a hospital is twice as likely to result in your death [than] a drive on America’s highways.”

16. Where are we now? • IOM set a goal of 50% reduction in errors by 2004

17. HealthGrades Patient Safety (2004) • Study of 37 million patient records, all Medicare, in 50 states + DC. • Medicare 45% of all hospital admissions excluding OB • 195,000 deaths annually due to in-hospital medical errors (2000-2002) • Since the original report in 1999: • 1 - 2 million more people have died due to preventable medical errors or hospital-acquired infection

18. January 2012 report • Reported January 6 in NY Times • Department of Health and Human Services • Medicare patients • Hospitals are required to track medical errors and adverse patient events and conduct a root cause analysis • Records review by independent doctors • How many medical errors are reported?

19. Recalculating…….recalculating….. • 130,000 Medicare beneficiaries experience one or more adverse events in hospitals • EVERY MONTH

20. Raleigh General Hospital, W.Va. • Anesthetic Awareness • Patients can feel all the pain, pressure, discomfort during surgery…but cannot move or communicate with doctors • Occurs between 20,000 and 40,000 patients every year • Attributed to physician error or faculty equipment • Sometimes only part of the drugs are administered • W.Va. Patient committed suicide

21. Who makes the IV bags? • Two year old girl receiving IV chemo • Saline base prepared before adding chemo agents • Saline was 20 times stronger than ordered • High concentration of sodium caused brain edema and coma • Child died 3 days later

22. Who makes the IV bags? • Pharmacy tech • High school diploma • Pharmacist overseeing the work was fired, convinced of involuntary manslaughter • Jail time • House arrest • Loss of license, career • Fined

23. Who makes the IV bags? • Pharm techs have something to do with approximately 96% of pharmacy prescriptions • “Culture of Silence”

24. Who is “attending” you? • Medical Model Education • Student/intern? • Resident? • Chief resident? • Attending?

25. Who is “attending” you? • Fatal oversight: • Second year student doing “rounds” at UPenn • 71 year old patient recovering from hip replacement surgery • SOB, sweating • Classic signs of pulmonary embolism • “I hadn’t read that chapter yet” • Patient died

26. Adding to the problem • Most people feel that medical errors are the failures of individual providers • Delays in diagnosis and treatment? • But… • IOM showed most medical errors are “systems related”

27. Why do medical errors occur? • “Systems” errors • Fatigue* • Brigham and Women’s & Harvard • 3x higher error rate with 1x/ month 24 hour shift • 7x higher error rate with 5x/month 24 hour shifts • Lack of knowledge • 6000 known diagnoses • 4000 available drugs • Lack of communication *www.plosmedicine.org

28. Why do medical errors occur? • Poor charting • Impaired care providers • Survey of 1662 respondents • 46% failed to report at least one serious medical error • 45% failed to report an incompetent or impaired colleague *www.plosmedicine.org

29. Root Cause Analysis • “A process for identifying the basic factors that underlie variation in performance, including the possible occurrence of a sentinel event.” • Focuses on systems and processes, not on individual performances

33. A Case with a Bit More Relevance • “The fiasco which left seven veterans blinded” • Vawatchdog.org • 62 year old male veteran suffered “significant visual loss in one eye as a result of poorly controlled glaucoma” • January 2009

34. A Case with a Bit More Relevance • In June 2005, the patient was diagnosed as a “glaucoma suspect” • Allegedly, treatment wasn’t initiated • Prompted a review of 381 charts • 23 glaucoma patients experienced “progressive visual loss” while receiving treatment in the Optometry department • Root Cause Analysis: • Patients were not being sent to ophthalmology for treatment (required by hospital) • Some OD’s did not hold additional certification to treat glaucoma

35. Reality Check – August 9 2010 Archives of Internal Medicine • Do patients know the name of the doctor overseeing their care?

36. How many patients know their diagnosis? • Doctors said • Patients said

37. Adverse effects of drugs were discussed with patients? • Doctors said • Patients said

38. Fears and anxieties • “At least sometimes I discussed patients’ fears and anxieties with them” (doctors) • “I had fears/anxieties but I didn’t discuss them with my physician.” (patients)

39. Preventing Medical Errors

40. Partnership for Patients • Coalition between 2,900 hospitals and federal administration • Goal: Reduce medical errors and save 60,000 lives in three years

41. Reporting Errors • 27 states have laws that require hospitals to report publicly on infections that are developed in the hospital • In 2005, only 5 states participated • Obama administration not proposing new federal requirements for reporting

42. What can the patient/consumer do to help reduce errors? • Appoint a patient advocate! • Verify patient’s identity every time a care provider interacts with patient • Keep a log of doctor and nurse visits and instructions • Get results of all tests and labs • Write down all information pertinent to diagnosis, treatment, and care • ESPECIALLY medications ordered and dispensed • Keep a medication log of at-home and hospital-prescribed medications • Infection Control!

43. What can the patient/consumer do to help reduce errors? • Be your own advocate • Choose your hospital wisely • Most people choose based on doctor’s affiliations, location, or health plan • Big differences in hospitals: Up to a 30% difference in central-line infections from hospital to hospital • INFECTION CONTROL!

44. What can the patient/consumer do to help reduce errors? • Be mindful of your own medications • Drug errors are a leading cause of error • Bring a list of meds and dosages and keep one with you during transfers, etc • Know side effects and potential interactions • Know where your advocate keeps your medication log

45. What can the patient/consumer do to help reduce errors? • If you have a choice, choose a hospital using bar-coding to verify patient identity, medication instructions, etc. • If permitted, label everything you can with patient’s name

46. What can the patient/consumer do to help reduce errors? • Avoid wrong-site surgery • Write on your arm/leg/forehead “Operate here” • INFECTION CONTROL! • Make sure everyone touching the patient washes their hands • Clean common items in the hospital room such as television remotes, chair handles, door handles, etc. • Do not allow flowers to be near the patient

47. Hand washing • Video monitoring improved compliance by 40%

48. 2011 study 57 • 63% of health care workers’ uniforms have CFU’s • 11% multiple antibiotic resistance • Neckties

49. Stethoscopes? 58 • 1997 study • 100% of physicians’ stethoscopes had CFU’s • Mostly staph, strep • simple swabbing with alcohol pad reduced growth to non-pathogenic • 2011 study of ER workers’ stethoscopes • 55% had CFU’s • Mostly staph epi

50. EEWWWWW 59 • 2010 study • Culture-forming units on • 66% pens • 55% stethoscopes • 48% cell phones • 28% white coats