Transcript Medical Executive Committee

Physician
Basic Safety
Training
Note: This training is based on actual safety events that
happened in UC Health facilities. This is not bureaucracy –
it matters!
There are 20 slides and it will take you 10 minutes to
complete – please give safety a few minutes of your time.
This course meets Hospital initial physician
training requirements for:
Blood Borne Pathogen Training
General Workplace Safety
UC Medical CenterAnnual Review (STAR)
National Patient Safety Goals
Confirm Identity When Writing Orders
(National Patient Safety Goal #1)
Case Report:
A physician ordered amlodipine, atenolol, and hctz for a
patient. The nurse questioned the orders, the doctor
confirmed them, and a dose of each was given. The
doctor discovered later that he had written these orders
on the wrong patient.
Lesson Learned:
• Double-check patient identity when writing orders
(CPOE, the EMR, and paper).
• When someone expresses a concern, listen…. And
then take a moment to double-check – they might be
wrong but they might just be right also.
Keeping Verbal Orders Safe
Case Report:
A physician gave a verbal order for “5 of vercuronium” during
an emergent procedure. The nurse thought she heard
“versed” and gave that. When the patient was not paralyzed,
the doctor said to “give 5 more”. After the second failed dose,
they realized the error and gave the correct medication.
•
Lesson Learned:
• Try not to use verbal orders.
• If a verbal order is needed, give a complete order.
• Require the nurse to read back and verify what you said.
• Confirm aloud that what you heard was correct.
Do this verbal back-and-forth deliberately every time.
Never Pre-Sign a Form – It’s Fraud
Case Report:
This Discharge Summary form
was found in a patient's chart –
pre-dated and signed before it
was completed. Regulatory
agencies consider this to be
falsification of records and a
serious offense. Don’t do it!
Be Careful What Information Is Given to
Visitors and Relatives (HIPAA)
Case Report:
A surgeon spoke to family members after a procedure
and told them off-hand that the patient’s healing would
be a little slower because of his HIV. They had not
been aware of the patient’s HIV status previously.
Good privacy habits:
• Think about what you are disclosing and always ask
visitors to step out of the room before discussing
personal information. If the patient says it is OK for
them to stay – then you’re OK.
• Provide counseling in a private area whenever
possible. If not possible, make attempts to protect
privacy (e.g. – pull the curtains and talk softly).
Medication Reconciliation Is a
Physician Responsibility
Case Report:
An admitting physician listed a patient’s thyroid dose as
25 mcg in his H&P and that is what he ordered for the
patient. The patient's correct home dose was 150 mcg.
The patient had a tremor and high thyroid tests on
admission testing so that the dose was reduced to 12.5
mcg and that is what the patient was sent home on. He
was readmitted later with altered mental status and a
very low T4 and high TSH.
Lessons Learned:
Getting meds right when patients come in and go home
is really important and a physician responsibility.
Checking and Reconciling Allergies Is
Everyone’s Responsibility
Case Report: After checking office records and asking
the patient about allergies, a clinic patient was given
an IM dose of ceftriaxone. The patient collapsed from
anaphylaxis soon after. Later, it was discovered that he
had a previous allergic reaction to ceftriaxone
documented in Last Word.
Lessons Learned: Currently, UC Health has multiple
data systems which means multiple lists of allergies.
Cases like this one are one of the reasons we chose to
buy an integrated electronic health record (EPIC).
• It is important to check all available sources of allergy
information before prescribing medications.
Key Things to Know About Heparin Protocols
• There are 4 protocols for
infusion heparin.
• Using protocols reduces
errors - use a protocol
whenever possible.
• Heparin dosing is weightbased up to a point. If a
low-dose protocol patient
weighs more than 83 kg,
use 83 kg rather than their
true weight in the protocol.
Key Things to Know About Pain Management
• Use a pain scale to assess the
patient's perception of pain.
• A behavioral scale is used for nonresponsive patient.
• Whenever an order is written for an
IV titratible drip for sedation, the
physician must indicate the target
level of sedation.
• If more than one pain medication is
ordered for a patient, the physician
must provide clear instructions on
which medication is to be used first
and when to go to the second med.
Use Restraints Sparingly – Order and
Document Them Correctly When Used
• It is a patient right to be free from
restraints and seclusion unless
needed to protect himself or
others.
• Less restrictive measures must
be considered before ordering
restraints.
• All restraints require a physician
order, initial assessment (why are
the being used), and interval
reassessment.
Fall Prevention
(National Patient Safety Goal #9)
Case Report: A patient returned from the PACU/OR following
surgery. The patient was oriented but slightly confused from the
anesthesia. The nurse evaluated him but was called to care for
a patient having a seizure. Five minutes later, the nurse was
called back by the roommate saying the patient was on the
floor. The fall resulted in a complication and return to surgery.
All patients are assessed for fall risk at admission and during each shift as
required by our fall reduction program.
At UCMC, Fall Risk patients wear a yellow bracelet and will be
identified by a yellow or red magnet on the door.
At WCH, Fall Risk patients are identified by
a yellow magnet placed on the door.
Universal Protocol / Time Out
The challenge is not doing time outs, it's doing them well. Pay Attention!
Case Report: A patient had a left
pleural effusion. The physician tried a
right thoracentesis by mistake. The
patient got a pneumothorax. Records
showed a checkmark in the box on the
procedure note indicating that the
team had done a “time out”.
Lesson Learned: (1) “Timeouts” are a good safety practice
for anything you do that might hurt a patient or is irreversible.
(2) This is not about a check mark in the box on the form. The
challenge is to be mindful and really pay attention and check.
How to Report Safety Problems
• Put an incident report into the computer system (On the main
SharePoint page, click “Enter an Incident Report” and follow
the prompts)
Patient Safety Hotline UC Medical Center: 584-2109
Anyone wishing to identify a potentially unsafe act,
process, procedure or system can call into the
hotline from any hospital phone line. This can be
used for reporting near misses, or when you are
unsure of the proper channel to report an incident.
Any report may be anonymous.
Better Documentation for Quality
Remains a Key Priority
Case Report: Several years ago, UC Medical Center(and
its physicians) were rated as “Worse Than National
Average” for pneumonia mortality. When we investigated
this we found many documentation and coding problems. A
coding improvement initiative was started and now UH is
back in the “Same as National Average” range.
Lessons Learned: There are a lot of organizations who
are “measuring” and reporting our “quality” on the internet
using publicly-available claims data and statistical risk
models. How our quality appears in such models depends
on how well we document what patients really have.
Electronic Health Records Downtime
Case Report: Our previous system went down on a Sunday
morning and stayed down for 14 hours. Some staff were
unaware of how to perform normal functions without the
computer and had trouble getting lab and x-ray results.
As with any computer system, downtimes are a reality. This
can happen with EPIC too. Each unit has a “Downtime
Packet” with detailed plans on what to do and a computer
with running records of key information such as patient
medications. If a downtime occurs, consult the Downtime
Packet, identify the downtime computer, and contact
radiology and the lab by phone for needed test results.
Fire Safety in the Operating Room
Case Report: A patient was undergoing surgery and a
decision was made to enter the chest intraoperatively and
Chloroprep (alcohol and chlorhexidine) was applied to the skin
by a member of the surgical team. A Bovie was used to
cauterize bleeders. A fire occurred at the incision and involved
a lap sponge that was extinguished on the floor.
Every MD needs to be aware of the
flammability risks associated with
medical solutions, gases, surgical
materials, and electrocautery devices.
Fire Safety in the Operating Room
Fire can occur when an ignition source, oxidizer and
fuel are combined. These three elements constitute the
Fire Triangle and are abundant in the Operating Room.
Reducing Blood-Borne Pathogen Exposures
Case Report: A PCSA picked up a plastic bag
to dispose of it. Someone had placed bloody
fluid in the bag and a splash occurred into the
PCSA’s eyes and mouth from a hole in the bag
caused by improperly disposed sharps. An
OSHA inspection followed and the hospital
received an OSHA fine of $26,500. Please
dispose of blood and sharps correctly.
Additional Advice: Make sure you wear
Personal Protective Equipment (PPE) – gloves,
gowns, masks, eye protection, surgical caps,
hoods and shoe covers where necessary.
Place blood and other infectious waste in Red
biohazard containers.
Let’s Reduce Sharps Injuries
In 2012 there were 150 sharps-related injuries at UCMC,
and 17 sharps-related injuries at WCH. 65 of the injuries
were to residents and fellows.
Here is what to do to reduce your risk of sharps injuries
• Place sharps carefully in proper containers.
• Do not overfill sharps disposal containers. Containers should
be replaced when 3/4 full.
• Be sure nothing sticks or spills out of the container.
• Dispose of sharps disposal containers in bio-hazardous trash
container, NOT in regular trash.
• Clean reusable sharps carefully.
• Put sharps away in their proper places.
Do not recap or bend needles.
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