Presentation on theme: "Innovative Techniques for Physicians to Improve Safety Tammy Lundstrom, MD Detroit Medical Center-Wayne State University VP, Chief Quality and Safety Officer."— Presentation transcript:
Innovative Techniques for Physicians to Improve Safety Tammy Lundstrom, MD Detroit Medical Center-Wayne State University VP, Chief Quality and Safety Officer
Detroit Medical Center 13,000 employees 3000 physicians 1000 Graduate Medical Residents 1000 Medical Students Nursing Students Pharmacy Students PA Students
Demonstration of Leadership Support Name of System Quality Council changed to System Quality-Medical Safety Council Chief Medical Safety Officer named Medical Safety Committee Established Monthly reports to the Board Medical Safety Plan Developed
Value of a Comprehensive Program Reduce fear of reporting errors/near misses, gather more data Reduce errors through tracking, trending,analysis, and targeted improvement projects Reduce errors through prevention
First Steps Common definitions agreed upon Common database to enter events Information flows through each site Leadership and Performance Improvement Committee Information flows from site to system Critical aspects of safety agreed upon
What is a Safety Culture And how is it achieved?
Lessons from a Leader “Safety is not a priority, it’s a way of life” Paul O’Neill CEO Alcoa Steel Treasury Secretary
Safety Culture Involves Paradigm Shift OLD Who did it? Focus on bad event -Root Cause Top down Punish bad behavior NEW What happened? Focus on Near Miss -FMEA Bottom up Fix broken processes
Advantage to Focus on near Misses No patient harm, therefore no blame No guilt Focus on prevention No fear of litigation
Disclosure of Unanticipated Outcomes to Patients and Families
What is an Unanticipated Outcome? A negative or unexpected result stemming from –A diagnostic test, medical judgment or treatment, surgical intervention, or (commission) –The failure to perform a necessary test, treatment, or intervention (omission)
Why Disclosure? We are our patient’s advocates Literature shows that after an unanticipated outcome, the patient and family want to know honestly what happened, and how the hospital is going to prevent future events Rebuilds trust Caregiver/Doctor relationship
Advocating Disclosure American Society for Healthcare Risk Managers JCAHO AHA AMA
JCAHO Standard RI.1.2.2 Patients and, when appropriate, their families are informed about the outcomes of care, including unanticipated outcomes.
AHA Develop an institutional policy or position statement on disclosure of unanticipated outcomes Differentiate between disclosure of an unanticipated outcome and an admission of liability Determine who will be responsible for informing the patient, and, where appropriate, the family and/or legal representative, about the unanticipated outcome. Educate caregivers and staff about your organization’s policies and procedures covering this issue, and consider communications training for those charged with disclosing unanticipated outcomes Specify documentation requirements regarding disclosure
ASHRM Each Healthcare institution must develop it’s own policy on management of unanticipated outcomes Disclosure of such information to patients and families must reflect the requirements of applicable law Differentiate between unanticipated outcome and admission of liability
For additional detail on implementation of a policy on disclosure of outcomes, consistent with the requirements of this standard:
Steps to Follow After Event Care for immediate needs of patient Preserve evidence (Medical equipment) Document in the medical record Report (Risk Management) Disclose
Documentation Document only the facts of what occurred and treatment rendered NOT –Blame –Subjective feelings, opinions –Speculation –Reference to “Incident report”
Incident Report Complete and submit Notify Risk Management FDA notification if Medical Device or Medication Begin Root Cause/Intensive analysis to examine process changes that may prevent future events
Who Will Inform the patient? The attending physician May need pre-disclosure conference with Nursing, Risk Management All patient questions should be referred to the attending physician
When Should Disclosure Occur? As soon as possible after immediate needs of patient addressed Gather facts FIRST May not have all the facts yet, in which case DON’T SPECULATE! Offer to speak again as facts become known
How? Convey compassion –“I am sorry for your…..” “I am sorry that you…” Known facts Privacy No BLAME on any member of healthcare team Avoid defensive posture/reaction Respond to patient complaints (provide forms, contact patient advocates/ombudsman)
Health Care Worker Involved in Error AVOID BLAME Provide counseling, if needed Remember: No one goes to work intending to make a mistake HCW feel tremendous guilt after event that harms patient
Examples from the Front Lines Physician Leadership is Key
Medication Safety Large % medication errors due to prescribing (20-49%) For the most part- physicians prescribe DMC Medication Safety Committee –Physician Chair –Review all events –Review ISMP alerts/External incidents –Chemotherapy Administration Policy
Medication Safety- Physician Lead PI Look-alike Sound-alike Posters and alerts Define safe medication order writing policy/pocket card Promote physician incident entry Develop delineation of privileges form related to chemotherapy administration
Dangerous Abbreviation Intended MeaningMisinterpretationRecommendation UUnitsMistaken as a zero or a four when poorly written, resulting in overdose. (4U seen as "40" or 4U seen as "44") Use units gg MicrogramsMistaken for "mg" when handwritten, resulting in overdose Use mcg q.o.d. or Q.O.D. Every other dayMisinterpreted as qd or qid if the "o" is poorly written. Use every other day or q 48 hours and time/day to begin therapy TIWThree times a weekMisinterpreted as "three times a day" or "twice a week" Use three times a week ccCubic centimetersMisread as "u" (units)Use mL AU AS AD Both ears Left ear Right ear Misinterpreted as "OU", "OS", and "OD".Use both ears, left ear or right ear OU OS OD Both eyes Left eye Right eye Misinterpreted as "AU", "AS', and "AD"Use both eyes, left eye or right eye
Board Support All physicians and trainees will have 3 hours of mandated compliance and safety education each credentialing cycle Failure to complete required education will be deemed voluntary resignation Web-based Continuing Medical Education credits Required for all new applications to the Medical Staff Physician experts develop and approve education modules
Physician Education Modules Sexual Harassment Code of Conduct Pain Management Medical Safety and Incident Reporting Restraint Use Conscious Sedation Infection Control Life Safety
Moderate Sedation for Physicians and Licensed Independent Practitioners
Moderate Sedation Moderate sedation/analgesia describes a drug- induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
Moderate Sedation Patient Evaluation Standards History and Physical includes: –abnormalities of major organ systems with specific focus on the cardiopulmonary history –pregnancy status –previous adverse experiences with sedation/analgesia, as well as anesthetic techniques –current medications and drug allergies/adverse reactions –time and nature of last oral intake of foods, fluids, etc. –history of tobacco, alcohol, or substance use or abuse
Moderate Sedation Patient Evaluation Standards Focused physical exam that minimally includes an evaluation of the airway and auscultation of the heart and lungs. Assignment of ASA Classification of Physical Status Pre-procedure laboratory and diagnositic testing guided by the patient’s underlying medical condition. History and physical examination are valid up to 30 days prior to the scheduled procedure. Verification and review of this information is necessary immediately prior to the provision of moderate sedation.
Moderate Sedation Monitoring Standards Level of consciousness –Monitoring the patient’s response to verbal and/or tactile stimuli should be routine (unless contraindicated by procedure). Pulmonary Ventilation –Ventilatory function is continually monitored by observation and/or auscultation during the procedure. Oxygenation –Continuously monitored by pulse oximetry with appropriate low limit alarms. Hemodynamics –Baseline blood pressure established; measured at regular intervals intra and post-procedure. Electrocardiograph continuously monitored.
Moderate Sedation Discharge Criteria Following the provision of moderate sedation, patients are monitored until they are suitable for discharge: –Level of consciousness and hemodynamic/respiratory variables evaluated and no longer at risk for sedation and cardiorespiratory depression. –For patients who received pharmacologic antagonists, post- procedure monitoring should continue for a sufficient period of time to detect and appropriately treat its recurrence. Discharge criteria that pertain to the patient population and specific procedures is developed: –A qualified physician or registered nurse should be in attendance until discharge criteria are fulfilled.
Incident Reports Incident Occurs Root Cause -Process Peer Review -Physician specific practice as it relates to care of this patient
Goal of Peer Review Monitor and improve physician care of patients Accomplish by: –Open, non-punitive discussion –Review and discuss alternatives –Disseminate to ALL physicians Monthly Vignettes
Code Blue Get away from “monitoring Code” Move towards: review previous 48 hour record –Could this event have been prevented? –Were signs of deterioration missed? Elevated BP, dropping BP Elevated HR, dropping HR Elevated RR