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© 2012 American Academy of Neurology Patient Safety 101 for Neurologists.

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1 © 2012 American Academy of Neurology Patient Safety 101 for Neurologists

2 ©2012 American Academy of Neurology Overview  The history of patient safety  Situations that lead to medical errors  Case studies  How do we avoid medical errors

3 ©2012 American Academy of Neurology Patient Safety: The History  Hippocrates – “Primum Non Nocere” Beneficence Beneficence Non-malfeasance Non-malfeasance  Florence Nightingale “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.” “It may seem a strange principle to enunciate as the very first requirement in a Hospital that it should do the sick no harm.”

4 ©2012 American Academy of Neurology The History of Patient Safety  Post-World War II Modern advances in the ability of medicine to help were accompanied by a corresponding increase in the ability to do harm  Studies of the impact of medical errors began to appear in late 1980s to early 1990s Harvard Medical Practice Study Reviewed >30,000 charts from randomly selected patients in acute and non-acute hospitals in New York o 3.6% of hospitalized patients experienced adverse events resulting in harm o 70% of these events resulted in disability lasting less than 6 months, 13.6% resulted in death, 2.7% permanent disability

5 ©2012 American Academy of Neurology The History of Patient Safety  Quality of Australian Health Care Study in 1995 Placed greater emphasis on quality of care than negligence, i.e., could the adverse event be prevented? Reviewed >14,000 charts from 28 hospitals 16.6% of hospitalized patients experienced adverse events o 77.1% of those had disability lasting less 12 months o 13.7% with permanent disability o 4.9% ended in death 51% of the adverse events were considered preventable

6 ©2012 American Academy of Neurology The History of Patient Safety  In early 1995 an epidemic of errors erupted Michigan --a surgeon performing a mastectomy on a 69- year-old patient removed the wrong breast New York--a woman died when a doctor mistook her dialysis catheter for a feeding tube and ordered food to be pumped into her abdomen Tampa --a 51-year-old diabetic had the wrong foot amputated and a 73-year-old retired electrician died when a therapist mistakenly disconnected his ventilator

7 ©2012 American Academy of Neurology The History of Patient Safety  Institute of Medicine Report “To Err is Human” Landmark paper published in 1999  Estimated incidence of patients who die in hospital due to preventable medical error  Was the springboard for emphasis on patient safety, quality improvement initiatives, and ultimately pay for performance

8 ©2012 American Academy of Neurology What is Medical Error?  Definition according to IOM Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim Examples: adverse drug events surgical injuries and wrong-site surgery restraint-related injuries or death falls pressure ulcers

9 ©2012 American Academy of Neurology The History of Patient Safety: IOM report “To Err is Human”  Medical error is the 8th leading cause of death in the US.  Medical errors cause 98,000 deaths per year.  More people die from medical error than from breast cancer, HIV, or MVAs.

10 ©2012 American Academy of Neurology Types of Error  Diagnostic Failure to order appropriate test Delay in diagnosis Failure to act on results or monitoring  Treatment Error in the performance of an operation, procedure, or test Error in administering the treatment Error in the dose or method of using a drug  Preventative Failure to provide appropriate monitoring or follow-up Failure to provide prophylactic treatment  Other Failure of communication Equipment failure Other system failure

11 USA TODAY Thursday, June 28, 2001 Hospital mistakes must be disclosed Accreditation at risk if patients aren’t told By Robert Davis Hospitals must now tell patients and their families when they have been hurt by a medical error, according to nationwide standards that take effect Sunday. The standards by the nation’s leading health care accrediting agency are the first to hold hospitals accountable for a higher level of patient safety. …

12 ©2012 American Academy of Neurology How Unsafe is Healthcare?? Deaths per 100 million hours Being pregnant1 Traveling by train5 Working at home8 Working in agriculture 10 Driving 50 Working in construction67 Being hospitalized2000

13 ©2012 American Academy of Neurology Cost of Medical Error  Estimated direct cost of medical error in US $17 billion  Preventable adverse events to Medicare patients estimated to cost in excess of $880 million annually  A study from 2008 revealed overall cost of medical error in the US to be >$19.5 billion Total cost per error approx. $13,000 >2500 avoidable deaths >10 million days of lost productivity at work, costing $1.1 billion in short-term disability claims

14 ©2012 American Academy of Neurology Cost of Most Common Medical Errors Event Number of injuries 2008 % considered due to error Medical cost per event Total cost per event Pressure ulcers394,699>90$8730$10,288 Post-operative infections 265,995>90$13,312$14,458 Mechanical complication of device, implant or graft 268, $17,709$18,771 Hemorrhage complicating procedure 156, $8,665$12,272

15 ©2012 American Academy of Neurology Why is Healthcare Prone to Error?  Multiple and varied interactions with technology  Many individuals involved in care  Multiple hand-offs  High acuity of illness  Distracting work environment  Rapid, time-pressured decisions  High volume, unpredictable patient flow  Multiple step processes

16 ©2012 American Academy of Neurology Why is Patient Safety Important to Me?  It can save lives  It can make YOU a better physician  It is part of every hospital plan – no matter where you work  Focused programs are required by the Joint Commission  It is a required part of resident education curriculum by the ACGME and RRC

17 ©2012 American Academy of Neurology How Does This Affect Neurology?  Many patient groups at risk Stroke patients with many comorbid illnesses Potential for drug interactions High risk for falls Seizure patients with poor compliance or complex regimens Parkinson’s patients and dementia patients Significant cognitive impairment may result in medication error Physical disabilities may increase risk of falls and injury

18 ©2012 American Academy of Neurology Of the 300 neurologic lawsuits requiring a pay out in 2004, most common diagnoses:  Disc disorder  Stroke  Headaches/migraine  Seizure  Cancer  Meningitis  Paralysis  Aneurysm

19 ©2012 American Academy of Neurology National Academy of Science’s Institute of Medicine (IOM)  In 2001, the IOM laid out six dimensions of quality for health care.  According to the IOM, health care should be Safe Effective Patient-centered Timely Efficient Equitable

20 ©2012 American Academy of Neurology Patient Safety and Quality Improvement Act of 2005  Signed into Law 7/29/05  Nationwide Goals “To encourage the voluntary reporting of medical errors” Report to “Certified Patient Safety Organizations”  Many providers fear repercussions Act provides federal legal privilege and confidentiality protection

21 ©2012 American Academy of Neurology Location of Patient Safety Organizations by State

22 ©2012 American Academy of Neurology Joint Commission Goals  Improve the accuracy of patient identification “NEVER” events  Improve the effectiveness of communication among caregivers  Improve the safety of using medications  Reduce the likelihood of patient harm associated with the use of anticoagulation therapy  Reduce the risk of health care-associated infections

23 ©2012 American Academy of Neurology Joint Commission Goals  Accurately and completely reconcile medications across the continuum of care  Reduce the risk of patient harm resulting from falls  Encourage patients’ active involvement in their own care as a patient safety strategy  Recognize and respond to changes in a patient’s condition

24 Crossing the Quality Chasm– IOM report IOM was supposed to be balanced  “…to strike a balance between regulatory and market-based initiatives, and between the roles of professionals and organizations” But it was compliance-heavy  “…to create sufficient pressure to make errors so costly in terms of ability to conduct business in the marketplace, market share and reputation that the organization must take action”

25 JCAHO Establish disease -specific care performance indicators and mandatory reporting for accreditation High quality SAFE patient care Government Monitor provider organizations through mandatory and voluntary reporting Employers Provide incentives to providers that use tools to increase safety. Providers Implement tools that support clinical decision making and prepare for new reporting requirements. Payors Provide incentives to providers that use tools to increase safety and can demonstrate performance IOM Stakeholders

26 ©2012 American Academy of Neurology “Traditional” Patient Safety Honored traditional teaching Blame… Shame… Denial… Errors are caused by… Time-honored solutions to error? Anger… Shoot the messenger… Work harder…Try harder… Blame the system…

27 ©2012 American Academy of Neurology “Culture” The system of shared beliefs, values, customs, behaviors, and artifacts that the members of that society use to cope with their world and one another, AND … that are transmitted from generation to generation through learning.

28 ©2012 American Academy of Neurology “Culture of Safety” Acknowledges high-risk, error-prone nature of modern health care Shared acceptance of responsibility for risk reduction Encourages open communication about safety concerns in non-punitive environment

29 ©2012 American Academy of Neurology “Culture of Safety” Facilitates reporting of errors and safety concerns Learns from errors and redesigns safer systems Ensures that organizational processes, goals, and rewards are aligned with improving patient safety



32 ©2012 American Academy of Neurology 1. Medication Errors  Occur frequently in hospitals Approximately 2% of admissions experienced preventable Adverse Drug Event (ADE) Estimated increased cost $5000 per patient ADEs cost about $5.6 million per hospital annually  Average cost per ADE in tertiary hospital $3244 with increased length of stay (LOS) of 2.2 days  Average cost per ADE in community hospital $3420 and increased LOS of 3.1 days

33 ©2012 American Academy of Neurology Medication Errors  Most common medications associated with harm Anticoagulants Antidepressants Antipsychotic medications Cardiovascular drugs Analgesics

34 ©2012 American Academy of Neurology Predictors of ADEs  Cannot solely be predicted based on patient factors or drug types  Some associated risks: Older age Polypharmacy Severity of illness

35 ©2012 American Academy of Neurology Medication Errors: What can you do to reduce error or potential harm? Check your orders for accuracy of dosing Check medication interactions Ask specifically about herbals and OTC products Check medication side effects and ask the patient about these on subsequent visits Check to see that the patient is receiving the medication as prescribed Encourage patients to bring in written lists Use EHR


37 ©2012 American Academy of Neurology 2. Poor Communication  In an average 4-day hospital stay, a single patient may encounter up to 50 different hospital employees  More than 1/5 of patients reported hospital system problems Staff providing conflicting information Not clear who the physician responsible for their care is

38 ©2012 American Academy of Neurology Poor Communication  With ineffective communication, great potential for harm Lack of critical information Misinterpretation of information Overlooked change in status Unclear orders over the phone  Communication errors identified as the root cause of sentinel (“Never”) events reported to the Joint Commission from 1995 to 2004

39 ©2012 American Academy of Neurology Barriers to Effective Communication  Hierarchical differences  Inter-professional and intra-professional rivalries  The health literacy of the patient  Differences in language and jargon  Cultural differences  Generational differences

40 ©2012 American Academy of Neurology Barriers to Effective Communication  Despite your best efforts to communicate and your belief that your have communicated effectively, more patients than you may realize don’t understand what you think they understand.  Rarely will patients reveal limitations in their understanding because they are embarrassed to do so.

41 ©2012 American Academy of Neurology Barriers to Effective Communication  Health Literacy - Factors affecting patients’ ability to understand Ability to read Ability to understand English Ability to understand medical “lingo” Cultural / ethnic views of cause and treatment of disease Complexities of health care system

42 ©2012 American Academy of Neurology What can we do to improve communication within the health care team? Ensure that the information is conveyed between staff members at shift changes. Written sign out including diagnosis, clinical status of patient, pending results, key test results, allergies, CODE status, and “what to do if…” If possible, bring the nurse into the room to demonstrate the current findings and specific things that you want to be notified about. Document the teaching and follow-up. ASSUME NOTHING!

43 ©2012 American Academy of Neurology What can we do to promote effective communication with our patients?  Speak in plain everyday terms– avoid medical jargon  Use teach-back methods  When possible utilize pictures or diagrams  Provide written information or handouts  Make every attempt to use a medical translator for those patients who are non-English speakers

44 ©2012 American Academy of Neurology 3. Infection Resulting from Lines and Tubes  Don’t use a Foley catheter unless it is absolutely necessary.  Lines should be dated and checked daily  Lines should be removed as early as possible, and if there is ANY sign of infection As of 2009, CMS and some insurance companies will not pay for infections that develop once a patient is in the hospital

45 ©2012 American Academy of Neurology 4. The Patient is Not Sufficiently Monitored  Patients may need frequent vitals monitoring, telemetry, serial lab testing depending on their condition  No one will fault you for being “overly cautious”

46 ©2012 American Academy of Neurology 5. Handwriting  Errors in misinterpretation of written orders account for a large percentage of inpatient mistakes. Avoid use of trailing zeros Use 5mg not 5.0mg Use leading zeros 0.5mg  Standardized order sets are used to help decrease orders of OMISSION. However may increase orders of COMMISSION due to duplication of tests or inappropriate medications/tests  Use of electronic health record systems can reduce errors caused by handwriting

47 ©2012 American Academy of Neurology 6. The Diagnosis is Not Clear  A wrong diagnosis is made because of failure to order the appropriate test  Always evaluate for life-threatening processes that require immediate attention (stroke, myocardial ischemia, pulmonary embolism, intracranial hemorrhage) as appropriate  Review all test results in a timely fashion to ensure that patients are treated appropriately  Who will notify the patient about their test results? How will they be notified?

48 ©2012 American Academy of Neurology 7. New Information is Ignored  Lab results in clinic resulted but not reviewed or patient not notified of result  Additional history from patient or family  A patient admitted for one thing may develop a new problem while hospitalized (e.g., patient with a stroke develops an MI)

49 ©2012 American Academy of Neurology 8. The Patient Who Needs Frequent Blood Monitoring: Diabetes and Anticoagulation  Insulin dosing errors in patients who are not eating  Glucose fluctuations in patients who have infections/stress of illness  Increased risk for bleed in anticoagulated patients  Interactions with other medications Ex. Many drugs interact with warfarin and may cause INR to increase or decrease Ex. Antibiotics may interact with and alter levels of anti-epileptic drugs


51 ©2012 American Academy of Neurology THE PHYSICIAN WHO ASSUMES THAT ERRORS DO NOT OCCUR!  If we carefully review our work, we are less likely to make errors  We should avoid making the same mistakes over again- system and practice change “If you don’t have time to do it right the first time, how are you going to have the time to go back and fix it later?”


53 ©2012 American Academy of Neurology Case 1  Patient admitted to stroke service by night float resident (or hospitalist). EKG ordered as part of standard order set.  EKG result not reviewed by the night float (hospitalist); signed out by phone to the day resident (or next shift) who has 4 new admits and forgets to check about the EKG.  Medicine consulted for HTN management 2 days later and notices EKG with evidence of MI on admit.

54 ©2012 American Academy of Neurology Case 1: Key Learning Points  Review all test results and history at time of admission and also transitions of care  Adequate handoffs and sign-out are critical, optimally are written  Communication between providers is best done face to face

55 ©2012 American Academy of Neurology Case 2  Neurology consulted for patient with delirium in ER  The patient has history of seizures. Lab tests reveal a phenytoin level of 65, and patient is ataxic on exam  Resident does not communicate situation to nursing staff Patient is placed in room away from nursing station without bedrails up, and no falls precautions noted.  Patient falls out of bed attempting to go to bathroom and suffers subarachnoid hemorrhage and subdural hematoma.

56 ©2012 American Academy of Neurology Case 2: Key Learning Points  Recognition of adverse drug event—supratherapeutic drug level. Why?  Failure to follow up on test result  Communication between providers and care team members  Inadequate supervision of falls risk patient

57 ©2012 American Academy of Neurology Case 3  Neurology patient admitted to the ICU for status epilepticus  Patient seizing for several hours with a low valproic acid level  Valproate level was not being monitored and was dosed incorrectly  ICU team not aware of when to call neurology  Neurology cross-cover had no sign out for “bed check” or lab follow-up

58 ©2012 American Academy of Neurology Case 4  Patient presented to the ER with mental status change and found to have a pneumonia.  Neurology consulted because of strange eye findings.  Neurology resident recommended head CT in the ER but never looked at the scan.  Patient admitted to medicine for the pneumonia and never had head CT done until 24 hours later, which reveals an acute obstructive hydrocephalus.

59 ©2012 American Academy of Neurology Case 5  Patient admitted to stroke service with new atrial fibrillation and put on warfarin.  Patient discharged to PCP for follow up.  PCP never received notification of admission and discharge recommendations, was not following INR, and also thought that patient was not a warfarin candidate because of falls.  Patient is readmitted for second stroke 30 days later with INR of 1.1, even though patient reported compliance with medication.


61 ©2012 American Academy of Neurology Impact of Error on Caregivers  Surgeons who believed they made medical errors 3 x more likely to consider suicide (Archives of Surgery)  Survey by Amy Waterman of 3100 physicians 92% reported a “near miss” or a minor error 57% reported a serious mistake Of those who reported serious error  2/3 reported anxiety about future error  50% reported decreased job confidence and satisfaction

62 ©2012 American Academy of Neurology How Do We Avoid Medical Errors?  Recognize the most common errors and take steps to avoid them Review records, orders, admission and discharge information Review orders and medications at times of transfer between units Review vital signs daily or more frequently as possible as these are early signs of changes in clinical status Review all test results in a timely fashion Identify patients at risk for falls Write clearly

63 ©2012 American Academy of Neurology How to Avoid Medical Errors?  Review medication lists at EVERY appointment  Have a formal sign-out or hand-off procedure  Provide written communication to referring providers in a timely fashion

64 ©2012 American Academy of Neurology How to Avoid Medical Errors?  Make sure there is a clear follow up plan Provide appointment on discharge summary for patients discharged from the hospital  Provide written information about medications or diagnoses  Discuss discharge planning with case managers early so that patients are not waiting extra days in the hospital for rehab therapy or home health services to be arranged

65 ©2012 American Academy of Neurology How to Avoid Medical Errors?  All of these things take time... BUT  In the end it saves time and resources by reducing complications, length of stay, and cost to patients and systems.


67 ©2012 American Academy of Neurology Disclosing Errors  Required by the Joint Commission  Important elements of disclosure that matter most according to patients Disclosure of all harmful errors An explanation as to why the error occurred How the error's effects will be minimized Steps the physician (and organization) will take to prevent recurrences

68 ©2012 American Academy of Neurology Disclosing Errors  Doesn’t mean you talk to the patient or family without stopping to think first  You should tell the truth, but tell it wisely  This means: Not withholding key information Providing factual information in a timely manner while acknowledging if there is uncertainty about the course of events or the consequences of the error Speculation ≠ Truth

69 ©2012 American Academy of Neurology Disclosing Errors Wisely  First and foremost, when an error happens take care of the patient  Once the dust settles, get help Physician or nurse supervisors (preferably both)  Get the facts--and sometimes that takes time Was there a departure from a standard of care? Was the patient harmed? Was the error avoidable?  Don’t blame, point fingers, or gossip

70 ©2012 American Academy of Neurology Disclosing Errors Wisely  Get advice if necessary from Risk Management, the hospital attorney, or the ethics committee  Plan the disclosure—DON’T WING IT  The most skilled and responsible person should conduct the discussion Should not be delegated to an intern or other subordinate

71 ©2012 American Academy of Neurology Disclosure ≠ Liability  Disclosure is simply a statement that an error happened.  Liability requires: Negligence—departure from standard of care Damages—i.e., the patient was harmed Proximate cause—the harm resulted from the departure from the standard of care

72 ©2012 American Academy of Neurology Summary  Be aware of the potential for errors across all environments and systems in which patients are cared for  Communication is key!  Remove tubes/lines as early as possible  Practice preventive medicine e.g., DVT prophylaxis

73 ©2012 American Academy of Neurology References 1. Nightingale, Florence. Notes on Hospitals. London: Longman, Green, Longman, Roberts and Green, Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370–7. 3. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australia Health Care Study. Med J Aust 1995;163:458– Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press, Leape L, Lawthers AG, Brennan TA, et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, Layde, P. M., Meurer, L.N., Guse, C., Meurer, J. R., Yang, H., Laud, P., Kuhn, E.M., Brasel, K.J., & Hargarten, S.W. Medical Injury Identification Using Hospital Discharge Data. Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality; AHRQ Publication Nos (1–4). Vol. 2;119–132.

74 ©2012 American Academy of Neurology References 7. Balthasar LH, Keohane C, Seger DL et al. Cost of adverse drug events in community hospitals. Jt Comm Jour on Qual and Patient Safety 2012; 38: Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review. Arch Intern Med 2003 Jun 23;163(12):1409– Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med 2006;166:

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