Transcript key article

Resident
Educator
Development
The RED Program
A Residents-as-Teachers Curriculum
Developed by Heather A. Thompson, MD
The RED Program
• Team Leadership
• How to Teach at the Bedside
• The Microskills Model: Teaching during Oral
Presentations
• How to Teach EBM
• The Ten Minute Talk
• Effective Feedback
• Professionalism
• Patient Safety and Medical Errors
Patient Safety and Medical
Errors
Medical Errors: Public Interest
• Institute of Medicine Report (1998)
• Errors are responsible for preventable injury
in as many as 1 out of 25 patients
• Errors estimated to cost more than $5
million per year in a large teaching hospital
– Total annual cost = $17 to $29 billion
• Estimated 44,000-98,000 people die each
year from medical errors
– more than MVAs, Breast ca, and AIDS
– 8th leading cause of death
Medical Errors: Media
Why include this in a Residents-asTeachers Program?
• Residents are in a unique position to identify
systems errors at a teaching hospital
• Residents can teach interns and students
how to approach medical errors
• Work hours rules, handoffs (night float, day
float) make reduction of error and reliable
systems of care all the more important
• To reduce the culture of “blame and shame”,
we need to start early on in medical training
ACP Patient Safety Curriculum
“Patient Safety—The Other Side of the Quality
Equation” Cristel Mottur-Pilson, PhD,
Principal Investigator
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Systems
Cognitive Capacity
Communication
Medication Errors
The Role of Patients
The Role of Electronics
Idealized Office Design
Objectives
• Define “system”
• Recognize the role of systems in both
allowing and preventing medical errors
• List several steps that residents can
take to prevent medical errors within
these systems: “take home points”
The Concept of Patient Safety
• Dates back to the time of the
Hippocratic Oath:
“I will prescribe a regimen for the good
of my patients according to my ability
and my judgment and NEVER DO
HARM TO ANYONE…”
The Concept of Patient Safety
• Patient Safety is defined as freedom from
injury (Kohn), or the absence of medical
errors or adverse events
• The IOM defines error:
“An error is defined as the failure of a
planned action to be completed as intended
(i.e. an error of execution) or the use of a
wrong plan to achieve an aim (i.e. error of
planning).”
The Concept of Patient Safety
• Adverse Event (AE): An injury
resulting from medical intervention,
not due to the patient’s underlying
condition
• Sentinel event: a “near miss” in which
an adverse event did not occur, but
alerts people to the possibility of a
future event
What is a system?
• A system is any collection of components
and the relations between them, whether
the components are human or not, when the
components have been brought together for
a well-defined goal or purpose.
--Moray
What is a system?
• Berwick’s law: Every system is
perfectly designed to produce exactly
the results it produces.
• To change the output or the “error
rate” of the system, we must change
the processes within the system, not
just fire the individual most closely tied
to the event.
What is a system?
• An error that results in an adverse
event usually occurs as a result of
numerous breakdowns or “holes”, each
at different points in the system.
• An error or a near-miss is an
opportunity to step back and analyze
the system.
Systems create “latent” errors
James
Reason.
BMJ (2000)
320:768-70
• Firing the last person: No help
View Video Clip
Resident and student discussing
erroneous report of blood culture
result
System Performance Improvement
• In general, all of our efforts are
focused on blaming a single person for
an isolated incident (such as the blood
culture result). This is wrong.
• Instead, we should focus on analyzing
the system and identifying areas for
improvement.
• Next: Cased based learning
Case one: Ordering a Scan
• One of your patients with chronic renal
failure is in the ER complaining of abdominal
pain.
• A CT of the abdomen is ordered. It is
written on the form: “CT abd w/o contrast.”
Diagnosis: “abd pain.”
• Radiology has trouble reading the
handwriting and orders a CT with contrast.
• The patient receives contrast without any
pre or post procedure hydration or
monitoring.
Where did the systems fail?
• The use of initials and abbreviations has
been shown to cause errors.
• The radiology department does not confirm
the study ordered when in doubt.
• There is no policy of verifying a patient’s
creatinine prior to contrast.
• The secondary diagnosis of renal failure is
not included on the ordering sheet.
• The patient was not involved (inquire about
allergies, medical history).
Other interesting handwriting
examples
Can you tell what drug this is?
Dispensed: Plendil
Intended: Isordil
Dispensed: Prozac
Intended: Buspar
Dispensed: Vasotec
Intended: Vantin
Dispensed: Fiorinal
Intended: Florinef
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.
Is it HCT (hydrocortisone) or
HCTZ (hydrochlorothiazide)?
Is it six units of insulin or sixty?
Tequin, not tegretol
Avandia, not coumadin
Case two: Telephone Medicine
• The wife of a 75 year old man calls the
resident’s continuity clinic because her
husband is “sick.”
• Paper message slip, generated by triage
nurse, is placed on the desk of the resident
(the “inbox”) without the chart.
• Paper note discovered two days later by
resident, during their scheduled clinic day.
• Chart is requested first; pt not called back
until later in the afternoon.
Case two: Telephone Medicine
• Wife states he is febrile and confused.
• Review of the chart reveals pt on high
dose prednisone.
• Pt is admitted to the hospital later that
day, and dies of overwhelming sepsis.
Where did the systems fail?
• Triage nurse did not ask pertinent questions
or review his medical history.
• Patient’s illness prevented him from calling-info obtained second hand, through wife.
• Wife did not appreciate sense of urgency; did
not call back after not hearing from clinic.
• Resident in clinic only one afternoon a week.
• Message passed to MD without retrieving the
patient’s chart first.
Case Three: Medication Mixup
• Patient comes to a busy ER with history of
eye pain after woodworking.
• Patient is to be administered topical
anesthetic/fluorescein eye drops and
examined for corneal abrasion.
• The resident rotating through the ER instead
grabs hemoccult developer bottle, which is
the same size and stored in the same drawer
below the examining table.
• Hemoccult developer is applied to the
patient’s eyes resulting in intense pain.
Where did the systems fail?
• Orient the resident to the ER, exam rooms.
• Avoid storing look-alike medications together
so they cannot be mistaken for one another.
• Ask the nurse/assistant to set up for the
procedure first, as a “second pair of eyes”.
• Or, create separate “kits” clearly marked for
use with all the needed components.
• Always verify that the medication or solution
you are about to use is the one intended.
• Under time pressure do not take shortcuts
but verify each step in the sequence.
Case Four: Dialysis Patient
• 20 yo female admitted at 6pm for clotted
dialysis fistula.
• Patient has a chemistry panel that evening, in
which the potassium was not reported. Lab
notes: “specimen hemolyzed.”
• Team orders lab to be redrawn, but instead of
redrawing that evening, chemistry panel is
added on to the am labs.
Case Four: Dialysis Patient
• In the morning, Renal is called for dialysis.
The response: “Not our patient, consult Peds
Renal.”
• The 7 am lab draw again is reported out as
“specimen hemolyzed.”
• No redraw is ordered, and the Renal team
has not yet been contacted.
• Team must leave postcall at noon. These
issue are passed onto day float.
Case Four: Dialysis Patient
• Technician notes that the t-waves are so tall
and peaked on the monitor, that she must
adjust the scale to capture the reading.
• After this, she notes QRS widening on the
strips. Handwritten note in chart is made,
but physicians are not called.
• At noon a code blue is called, patient is in
cardiac arrest, a sine-wave rhythm. Stat
potassium is 9.4.
Where did the systems fail?
• Outside records were not available. (Was the
patient typically dialyzed for volume?
Hyperkalemia?)
• Lab does not automatically redraw the
hemolyzed specimen, or notify the physician.
• Lab does not report an estimate of the
potassium level even if specimen hemolyzed.
Where did the systems fail?
• Ward clerk mistakenly added the redraw onto
the morning labs. Computerized physician
order entry (CPOE) may have prevented this.
• Technician did not call MD’s with changes on
the monitor.
• MD’s did not impress upon nursing or lab that
the chemistry panel was essential.
• Due to work hours limits, MD’s had to pass
along important tasks to the day float.
Case Five: Discharging a Patient
• Patient with cystic fibrosis is discharged from
the hospital from a teaching service after CF
exacerbation.
• Discharge medications include NPH and
regular insulin.
• Incorrect dose of NPH was written for (twice
the usual dose).
• Patient failed follow up appointment.
• Three weeks later patient found dead in his
apartment; autopsy revealed extremely low
orbital fluid glucose.
Where did the systems fail?
• Intern who wrote the discharge orders
wrote incorrect dose.
• Resident who dictated the discharge
summary dictated weeks later, did not
catch the error.
• Nurse who goes over the medications
with the patient on the day of discharge
did not notice the change.
Where did the systems fail?
• Pharmacy filling insulin prescription failed to
check with MDs or patient regarding dose
change (in this case, both prescriptions filled
at same pharmacy).
• Patient failed to clarify new dose with the
team.
• Patient failed follow up appointment.
Summary of Cases
• Note that in each case, an adverse
event was the result of multiple
overlapping points of breakdown within
the health care system.
• The adverse event was NOT the result
of the heinous acts of one individual.
What can we do?
• Recognize that resident physicians are just one part
of the system that delivers patient care.
• When you come across a medical error, think,
– Where did the systems fail?
– What systems, if put in place, could prevent this
from happening again?
• Discuss the error with the person (intern, student)
and also attending physician. Focus on the systems
issues at hand, and not just the individual.
• Know who to contact at the hospital when a sentinel
event occurs.
What can we do?
• Realize that redundancy within the system is
often necessary to prevent errors.
• As the senior resident, make your interactions
with each component of the system more
efficient, more effective, more patient
centered.
• Good communication is the key at every level.
Suggestions:
The physician-patient interaction
• Communicate effectively with the patient
regarding their disease, treatment, prognosis,
warning signs.
• Go over medications, including reason for
taking, side effects.
• Enlist the aid of the patient’s family and
caregivers: “talk to the family.”
• Give the patient written materials whenever
possible: UptoDate, Medline Plus.
• Give the patient detailed discharge
instructions upon leaving the hospital.
The physician-pharmacy interaction
• Prescriptions/orders should be written legibly,
or use electronic ordering systems.
• Write the indication for the drug on the
prescription to avoid confusion of “look-alikes”
(Celexa, Celebrex).
• When on the wards: use your PharmD.
• Cooperate when the pharmacist pages you to
clarify prescriptions.
The physician-nursing interaction
• Shortage of nurses mean fewer nurses caring
for more patients.
• Eliminate unnecessary nursing orders to free
them up for more important things (i.e.
going over discharge instructions.)
• Do you need vitals qid? I/O, daily weight?
• Always communicate your plan for the day
with the patient’s nurse or charge nurse.
• Always verbally communicate orders that are
especially important.
The physician-1˚MD interaction
• Potential for error very high from the
inpatient stay to the outpatient follow up.
• Verbally communicate with the primary MD
both during the hospital stay and on the day
of discharge.
• Dictate the discharge summaries in a timely
fashion and include the important follow up
issues—any change in medications, any
pending test results, any tests that need to
be scheduled as an outpatient.
Objectives
• Define “system”
• Recognize the role of systems in both
allowing and preventing medical errors
• List several steps that resident
physicians can take to prevent medical
errors within these systems: “take
home points”
Systems create “latent” errors
James
Reason.
BMJ (2000)
320:768-70
• Firing the last person: No help