Transcript actions - University of Colorado Denver

Four Actions
The Hospitalist’s Role in
Patient Safety
Mark B. Reid, MD
Division of Hospital Medicine
Denver Health Medical Center
University of Colorado: GIM TMC
February 17, 2009
Denver VA Hospital
To Err is Human: 1999
The flawed assumptions
 Safety results from complexity
 Errors are caused by bad people
 This problem will be easy to fix
What has Worked?
1. Regulation:
JCAHO
2. Reporting
3. Teamwork Training
4. IT
The End of the Beginning: Patient Safety Eight Years After the IOM Report on Medical Errors. Robert M.
Wachter, MD, 12th Annual Management of the Hospitalized Patient, San Francisco, CA October 23, 2008
Learning Objectives
1. Know when to wash your hands
2. Know who to call when an error occurs
3. Name one intimidating behavior
4. Name a common CPOE error
ACTIONS
1. Do JCAHO
2. Report errors
3. Be available
4. Beware computer errors
1. When rounding on your patients,
you foam or wash your hands:
A) never
B) before each patient
C) after each patient
D) whenever someone is watching
E) before and after each patient
1. When rounding on your patients,
you foam or wash your hands:
A) never
B) before each patient
C) after each patient
D) whenever someone is watching
E) before and after each patient
What has Worked?
1.
2.
3.
4.
Regulation: JCAHO = rules
Reporting
Teamwork Training
IT
Hand Hygiene
Donskey and Eckstein 360 (3): e3, Figure 1
January 15, 2009
Centers for Disease Control and Prevention. Guideline for Hand
Hygiene in Health-Care Settings: Recommendations of the
Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR
2002;51(No. RR-16)
# Washes ≥ [# Patients] + 1
Practical Script for Hand Hygiene
(hand washes are green arrows)
Check labs
P1
P2
P3
Time
Answer phone
P4
P5
Action 1
Do JCAHO
•National Patient Safety Goals: 2009
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Correctly identify patients
Read back telephone orders
“Do not use” abbreviations
Critical values
Standardized “hand-offs”
Look-alike/sound-alike drugs
Wash your hands
Reconcile medications @ admit and D/C
Identify patients at risk for suicide
Mark site/time out
2. A patient is transferred to the
floor from the MICU after a Tylenol
overdose. What special step(s)
should you take?
A) speak directly to the psychiatry
consultant
B) confirm that patient has a
mental health hold
C) assign patient to a sitter room
D) check his bag
E) all of the above
2. A patient is transferred to the
floor from the MICU after a Tylenol
overdose. What special step(s)
should you take?
A) speak directly to the psychiatry
consultant
B) confirm that patient has a
mental health hold
C) assign patient to a sitter room
D) check his bag
E) all of the above
What has Worked?
1.
2.
3.
4.
Regulation: JCAHO = rules
Reporting
Teamwork Training
IT
The Promise of Error Reporting:
Safety in Air Travel
Joint Commission:
National Patient Safety Goals
JCAHO Root Cause Analysis
• Hospitals obliged to report events to
JCAHO
• 42 reports covering “the worst” errors:
PCA by proxy, delays in treatment,
prevention of ventilator associated
death
• Example: 675 inpatient suicides
reported as sentinel events
• Sentinel Event Alert:
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/
JCAHO Root Cause Analysis:
Inpatient Suicide
• Incomplete suicide risk assessment at intake
• Failure to identify a contraband
• Incomplete communication among
caregivers.
• Assignment of the patient to an
inappropriate unit or location
The case of the pills in the bag
Action 2
Report Errors
Call Risk Management for “Never Events”
Wrong side/site surgery
Air embolism
Patient suicide
Death from medication error
Death from hypoglycemia (<60)
Stage 3 or 4 pressure ulcer
Death or severe disability from a fall
National Quality Forum Serious Reportable Events in Healthcare 2006 Update
3. A nurse tells you he noticed a
patient was unsteady on her feet.
The way you respond to this
information could save another
patient’s life.
A) yes
B) no
3. A nurse tells you he noticed a
patient was unsteady on her feet.
The way you respond to this
information could save another
patient’s life.
A) yes
B) no
What has Worked?
1.
2.
3.
4.
Regulation: JCAHO = rules
Reporting
Teamwork Training
IT
Crashing Flight Simulators
JCAHO
Behaviors that Undermine
a Culture of Safety
Intimidating and disruptive behaviors can
foster medical errors
Staff within institutions often perceive that
powerful, revenue-generating physicians are
“let off the hook”
A few commit many but many commit a few
http://www.jointcommission.org/SentinelEvents/SentinelEventsAlert/sea_40.htm
Are You an Intimidator?

Reluctance or refusal to answer
questions, return phone calls or pages

Use of condescending language or
voice intonation

Impatience with questions

Verbal outbursts or physical threats
TEAMWORK
Sutker, James Baylor Medical Grand Rounds, 7/17/2007
The Correct Response to
the Nurse
“Thanks for letting me know. That is
very important information. You
should always feel free to tell me
when you notice anything.”
Action 3
Be Available
Listen and respect staff opinions
Be approachable and available
Don’t be an intimidator
4. Do computers increase safety?
A) yes
B) no
4. Do computers increase safety?
A) yes
B) no
What has Worked?
1.
2.
3.
4.
Regulation: JCAHO = rules
Reporting
Teamwork Training
IT
New Errors in CPOE
New Errors in CPOE
1.
2.
3.
4.
Wrong patient selected
Loss of chart personality
Warning desensitization
Order set ignorance
Sutker, James Baylor Medical Grand Rounds, 7/17/2007
Action 4
Beware Computer Errors
1. Is this the right patient?
2. Look up drug doses, especially
for infrequently used medicines
3. Be redundant—talk to a human
being!
Learning Objectives
Did you learn anything?
1. Know when to wash your hands
2. Know who to call when an error occurs
3. Name one intimidating behavior
4. Name a common CPOE error
ACTIONS
1. Do JCAHO
2. Report errors
3. Be available
4. Beware computer errors
Questions?