Transcript Patient Safety

Stephen Loyd, M.D.
Associate Chief of Staff for Education
Mountain Home VA Medical Center
ABIM Board Review Series
Department of Medicine
Quillen College of Medicine
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IOM (2000)
 100,000 patients die per year as a result of
medical errors
 Preventable errors cost hospitals approximately
$20 billion
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Brigham and Women’s Hospital Self-Audit
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2005
233 serious errors
54 preventable adverse events
1,490 patient days
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61%- medication related
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53% of performance-level failures were slips
(not knowledge based)
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2/3 of adverse events don’t cause direct
patient harm (near misses)
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Root Cause Analysis (RCA)- group exercise to
determine the contributors to an adverse
event
Average of 5.9 systems-related or cognitive
factors that contribute to the diagnostic error
in each case, this confirms the Swiss Cheese
Model of error
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There must be breakdown of several layers of
a system to actually cause injury
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Were issues related to patient assessment a factor?
Were there issues with staff training or staff
competency?
Were there equipment issues?
Was the work environment a factor?
Was the lack of information (or misinterpretation of
information) a factor?
Was communication a factor?
Were appropriate rules/policies/procedures-or lack
thereof- a factor?
Was the failure of a barrier-designed to protect the
patient, staff, equipment or environment- a factor?
Were personnel or personal issues a factor?
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Health Systems must build redundancy into
its safety processes addressing the questions
posed in the RCA
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Build multiple layers of protection between a
patient and potential harm
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Airline pilot checklist used in the ICU- sedation
holidays, ventilator weaning and infection
prophylaxis addressed on morning rounds
“Time Out” policies prior to surgery- correct
patient name, kind of surgery planned and the
correct surgical site
EMR Systems- use “force function” to decrease
human error- automatic checks and reminders
for important quality indicators- i.e. “please
consider and ACE inhibitor in this patient with
heart failure.”
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Set up a culture of safety
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Healthcare team can openly discuss errors
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Teams are encouraged to analyze problems
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Collaboration occurs across disciplines to find
solutions in a systems-based approach
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Paul Batalden- “every process is perfectly
designed to deliver the results that it gets.”
People are rarely the source of errors,
processes are
The Plan-Do-Study-Act (PDSA) cycleeffective means for performance
improvement teams to implement changes
to address specific patient safety problems
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Goal- improve the timing of administration of
antibiotics to patients with pneumonia
Plan- test a simplified system (fewer steps)
Do- try the protocol on a limited number of
patients
Study- look at the results and summarize
what was learned
Act- refine the protocol based on what was
learned and plan the next test
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Total Quality Management (TQM)- typified by
the Baldridge National Quality Program
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Publishes evidence-based criteria which an
organization can judge its management
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Goal of TQM- build quality processes into
every level of the healthcare organization
Availability heuristic- a clinician has encountered
a similar presentation and jumps to a conclusion
that the current diagnosis must be the same
 Anchoring heuristic- clinician holds to an initial
impression that has been provided by a referring
physician- its accepted at face value
 Blind obedience to authority (resident to an
attending physician)
 Premature closure of the thought process can
prevent the expansion of a differential diagnosis
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Use of simulation to prevent common
diagnostic pitfalls
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Compile a complete differential diagnosis to
avoid premature closure
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Improve the accuracy of patient identification
Improve the effectiveness of communication among caregivers
Improve the safety of using medications
Reduce the risk of health care associated infections
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
Identify safety risks inherent in the organization’s patient
population
Improve recognition and response to changes in a patient’s
condition
Universal Protocol- conducting a pre-procedure verification
process, marking the procedure site, and performing a time-out
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Increased the use of hospitalist teams
Corresponding increases in the number of
handoffs between physicians
Best practices for handoffs
 Person to person communication
 Provides an opportunity to ask questions
 Accurate and concise information- “to do lists”,
“if/then” statements, severity of illness and
contingency plans