1. Resident Educator Development
The RED Program
A Residents-as-Teachers Curriculum
Developed by Heather A. Thompson, MD

2. 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

3. Patient Safety and Medical Errors

4. 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
Background info on medical errors research.

5. Medical Errors: Media
The lay press has brought the issue of medical errors to the attention of the general public.

6. Why include this in a Residents-as-Teachers 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
This topic is especially relevant during residency. Also, to analyze a medical error and why it occurred, by systems, is a great example of the ACGME Competency, Systems Based Medical Practice.

7. ACP Patient Safety Curriculum
“Patient Safety—The Other Side of the Quality Equation” Cristel Mottur-Pilson, PhD, Principal Investigator
Systems
Cognitive Capacity
Communication
Medication Errors
The Role of Patients
The Role of Electronics
Idealized Office Design
To give credit where credit is due: most of this material comes from two modules, “Systems” and “Idealized Office Design”, in the ACP curriculum. It was developed for widespread use at academic meetings, grand rounds, resident lectures, and the like.

8. 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”

9. 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…”
Not a new concept, but a very important one. First do no harm.

10. 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).”
Definitions.

11. 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
More definitions.

12. 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
Clinical examples: the outpatient clinic, the ward or ICU in the hospital, the operating suite—these are all systems. Many different components exist and interact (MDs, nursing, pharmacy, the lab computer, the monitoring equipment). The well defined goal or purpose is good patient care.

13. 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.
More systems theory.

14. 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.
More systems theory.

15. Systems create “latent” errors
To illustrate how systems create latent errors, or errors waiting to happen, here’s the famous Swiss cheese diagram.
You start with hazards [point], which are the risks that something will go wrong, and then in the system there are layers [point at first 3 layers] that could correct an error before it gets through and actually harms the patient. But these are imperfect and if the holes are big enough or if there aren’t enough layers it’s inevitable that they’re going to align sometimes just by chance and an error will get through to cause an adverse event.
The reason it says loss here [point] instead of harm or adverse event is that the diagram comes from James Reason, who’s been a leader in analyzing industrial accidents and who’s now applying the same principles to understanding patient safety.
The critical point, however, is that when an error does get through and somebody is harmed, it’s usually the person at the end of the line who gets blamed. In other words, when an adverse event happens [point at the arrow head] we look back and just see the last mistake in the chain, and we ignore all the latent errors that set the person up.
[click to bring up the last bullet] The real tragedy is that if you fire the person at the end of the line or you take away their license, it’s no help because you then put someone else into the same flawed system [point at first 3 layers]. In fact, there are some people who say that the person at the end of the line is really the second victim, not only of these latent errors in our practice systems but also of the system that punishes people for making mistakes. So what we need is to change the culture so that when something bad happens we look beyond the last person to focus on the system and its latent errors.
James Reason.
BMJ (2000) 320:768-70
Firing the last person: No help

16. View Video Clip
Resident and student discussing erroneous report of blood culture result

17. 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 based learning could include our examples, or actual clinical examples from your own experience or within your residency program.

18. 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.

19. 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).
May also want to add that CPOE (computerized physician order entry) may have eliminated this error.

20. Other interesting handwriting examples
Can you tell what drug this is?

21. Dispensed: Plendil Intended: Isordil
Jurors blamed this illegible prescription for the death of a Texas man. Although it allegedly calls for Isordil, the pharmacist misread it and filled it as Plendil. The jury’s $450,000 judgement, finding both the cardiologist and pharmacist negligent, is believed to be the first of its kind nationwide to focus solely on bad handwriting.
Dispensed: Plendil
Intended: Isordil

22. Dispensed: Prozac Intended: Buspar
Poor handwriting contributed to a medication dispensing error that resulted in a patient with depression receiving the antianxiety agent Buspar 10 mg instead of Prozac 10 mg
Dispensed: Prozac
Intended: Buspar

23. Dispensed: Vasotec Intended: Vantin
A hypertensive patient accidentally received Vasotec 20 mg instead of Vantin 200 mg when a pharmacist misread this prescription.
Dispensed: Vasotec
Intended: Vantin

24. Dispensed: Fiorinal Intended: Florinef
The importance of including the medication strength on a medication order is illustrated by a case in which a physician prescribed the medication above.
Since the order did not specify a strength or directions, a pharmacist misread the prescription as Fiorinal, a combination ingredient oral analgesic, instead of Florinef (fludrocortisone), for Addison’s Disease. The patient received the wrong medication for over a month and was finally hospitalized with severe electrolyte imbalance.
Had the strength been written (Florinef is available in 0.1 mg tablets) along with the directions (two tablets daily was intended), it’s doubtful that the pharmacist would have misread the prescription. Fiorinal is not a 0.1 mg tablet and rarely, if ever, is it prescribed for use on a “once-a-day” basis. Also, including both the brand and generic name on prescriptions would help to prevent this type of error. Had “Florinef (fludrocortisone)” been prescribed, it’s clear that this error would not have happened.
Dispensed: Fiorinal
Intended: Florinef
Cohen MR. Medication Errors. Causes, Prevention, and Risk Management;

25. Is it HCT (hydrocortisone) or HCTZ (hydrochlorothiazide)?
Resist the temptation to abbreviate drug names. In this prescription above, the common abbreviation for “hydrochlorthiazide 50 mg’ was misread as “hydrocortisone 250 mg.” In another case, an order for “AZT 100 mg” (a common abbreviation for the antiretroviral drug zidovudine - Retrovir) for a patient with AIDS, was misinterpreted as azathioprine (Imuran), an immunosuppressant. The potential harm in giving azathioprine to a patient with AIDS is obvious.

26. Is it six units of insulin or sixty?
This abbreviation (“U” for the word “unit) was misread as a zero which led to a patient receiving a ten-fold overdose of insulin.

27. Tequin, not tegretol Avandia, not coumadin
Here are two examples of look-alike drug names which, when combined with unclear handwriting, can lead to serious medication errors.
In the first case, is this an order for the flouroquinolone antibiotic Tequin (gatefloxacin) or Tegretol (carbamazepine), a drug used in epilepsy? In the other prescription order, is it the anticoagulant Coumadin (warfarin) or Avandia (rosiglitazone), used in the treatment of diabetes? Imagine the harm to a patient who received the wrong medication in either of these cases.

28. 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.

29. 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.

30. 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.
The top complaint noted in patient satisfaction surveys is regarding failed communication processes such as this one, and perceived unavailability of the physician (including unreturned phone calls.)

31. 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.
Similar clinical examples have occurred with injectable corticosteroids, lidocaine with or without epi, and administering drugs during a code (i.e. adenosine).

32. 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.
Nursing training stresses this concept—”right drug, right patient, right time”—but we as physicians often administer drugs ourselves. We need to be aware of the principles of safe drug administration as well.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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.

42. 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.

43. 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:

44. 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.

45. 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.

46. 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.

47. 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.

48. 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”
To summarize: relate back to the objectives.

49. Systems create “latent” errors
The most important take home point: the “Swiss Cheese” model.
James Reason.
BMJ (2000) 320:768-70
Firing the last person: No help