Transcript Lessons Learned on Patient Safety

Lessons Learned on
Patient Safety
FCC of MHRI
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
Levels of maturity with
respect to a safety culture
A. Why
waste our
time on
safety?
PATHOLOGICAL
B. We do
something
when we
have an
incident
REACTIVE
C. We have
systems in
place to
manage all
identified
risks
BUREAUCRATIC
D. We are
always on
the alert for
risks that
might
emerge
PROACTIVE
E. Risk
management
is an integral
part of
everything
that we do
GENERATIVE
Safety Minefields
• Transitions of Care
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– 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
Medication Pitfalls
• Survey says: 200,000 Rxs written
only 72% were filled
• Adherence and Medication
reconciliation
– Ask-Educate-Ask
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
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
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
Culture of Safety
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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
Tools
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Trigger Tools
Ambulatory Safety Survey: ARQHC
MGMA: Patient Safety Score
Donabedian: Structure + Process =
Outcome
• MaPSaF safety culture assessment
Trigger Tool
Primary Care Trigger
Tool
London Protocol
Tool Benefits
Individual Benefits
Framework Document
Next steps
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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