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Matters Patient Safety Matters Matters Challenges and Opportunities 2006 San Antonio 2005 11th European Forum 2006. Prague. WONCA AHRQ Resource Center.

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Presentation on theme: "Matters Patient Safety Matters Matters Challenges and Opportunities 2006 San Antonio 2005 11th European Forum 2006. Prague. WONCA AHRQ Resource Center."— Presentation transcript:

1 Matters Patient Safety Matters Matters Challenges and Opportunities 2006 San Antonio th European Forum Prague. WONCA AHRQ Resource Center How we see and deal with these matters And why are others Interested in our work ?

2 We are about Placing Patient Safety at the of Medical Education andPractice

3 CONTENT OF THIS AND THE OTHER THREE PRESENTATIONS CONTENT OF THIS AND THE OTHER THREE PRESENTATIONS Our Mission, Driving principles, Premises, and Implications The Burden of Lack of Safety on the Nation The Opportunity Our approach to lightening the Burden Main Areas of our Activity Education/training Safety Practice Enhancement Reporting & Taxonomy Covered in the other three presentations Covered in this presentation

4 Safety Practice Enhancements Current Situation Our Approach Our Aspiration Singh: April 2005 Our approach to lightening the Burden

5 Current Situation Singh: April 2005

6 The Patient Safety and Quality Improvement Act of 2005

7 Fear Kill the messenger (denial; shift the blame) Filter the data (game the system) Micromanage (Barking up the wrong tree) Scherkenbach’s Cycle of Fear, 1991

8 A, R & G Singh: Joint Commission: 2007 THIS IS MOST UNFORTUNATE Because…… Here is the EVIDENCE of manifestation of FEAR

9 Error reports are a rich source for understanding: *Causes of errors *Cascades of errors & *Consequences Background S S A, R & G Singh: Jan Safety Improvements Understanding

10 S S A, R & G Singh: Inventory of Reporting Systems 60 Systems >100 Reporting forms >1,500 Definitions of patient safety events >10,000 Event reporting variables Supporting documentation (System descriptions, reporting forms, encoding schemes, patient safety reports, etc.) From AHRQ: Battles At Least !! WHO has come up with another in 2007!

11 S S A, R & G Singh: Jan Singh: April 2005 There is not a single one that provides a structured view of safety in H.C. view of safety in H.C.

12 Our Innovative Approaches Practice Singh: April 2005

13 ALL workers “Swimming in the Water” can each see various parts at various times REPORTS PROFILES =Mechanistic AUDITS PLUS Survey of Errors and Consequences Leads to Survey of Errors and Consequences Leads to The Design of Targeted Interventions by the Energized Self Empowered Clinic Team The Design of Targeted Interventions by the Energized Self Empowered Clinic Team Why not ask them what they see? Comp/Supplementary Humanistic =Pursuit of Excellence G and R Singh 5% 95% But remember that reports are just the tip of the iceberg Let us at least see this tip more clearly

14 This part of the Presentation is based on publications by Singh et al.

15 Context S S A, R & G Singh: Jan Current error taxonomies consist of complex coding systems. These can present problems of ambiguity and they do not meet the needs of practitioners to understand, within their unique micro-system: causes cascades consequences

16 Context S S A, R & G Singh: Jan AND Taxonomies are just classifications of this or that type, and “grossly insufficient” Error reports that capture the “story” are the ones that have the potential to contribute to safety improvements. Billings 1998

17 Context 5 S S A, R & G Singh: Jan Visualization illustrates the ‘story’

18 Context 6 S S A, R & G Singh: Jan What we need is a visual interface to bring codes of taxonomy (and USNHII) to life

19 Context 5 S S A, R & G Singh: Jan Visualization is a Universal tool It is a natural common ‘language’ and provides : fastest path for fully engaging the minds of individuals and their teams insight to causes, cascades and consequences of errors common vision for team work leading to superior outcomes aid for coping with complexities, fragmentation and decentralization of the HC systems

20 Concept for: Internal and External Systems for Error Reporting and Classification that is useful for ALL members of the healthcare team (including Patients) at the Point of Care as well as at the Policy-making level We are (“experts”) contributors to the National and indirectly to the WHO efforts

21 The reporter must perceive it to be SAFE EASY WORTHWHILE Regional, National and International levels Unique Practice level Seamless flowFeedback and Alerts Concept Internal learning and improvement External learning and improvement Expressed in Universal Language Should be Dynamic, Evolutionary and System-oriented Singh: April 2005

22 PATIENT Perception Beliefs, Values Preferences Family, Friends Community access Assessment Plan Implementation Feedback Review & Learn Int. to H. Org. Ext. Based on History, exam, labs... Current problems Potential problems Curative Preventative Palliative Based on Investigations Drugs Behavior Mod. Physical Ther. Surgical No.1: Office Circle of Influence No. n: U.N. Health Authority Based at Pharmacy Home N.Home Hospital ---- From Patient Family Friends Nurses Physical therapist Surgeon Specialist HMO A 1P 1I1F 1R Based on Feedback History Current and past experience No. 0 Transitions A R G Singh: 2003/7 Micro-systems Macro-System of Health Care Errors can occur at each point in the system Based on Understanding of:

23 Searching the Visual Database Internal Ext. 1: Office PATIENT Perception Beliefs, Values Preferences Family, Friends Community 0: Home 2: ED 3: Hospital Select the Domain that you are interested in click on this domain

24 access Assessment Plan Implementation Review & Learn PATIENT Perception Beliefs, Values Preferences Family, Friends Community 1: Office Select the Process that you are interested in Domain: Office X = number of events reported in this process Searching the Visual Database Feedback click on this process

25 G and R Singh 2001 Micro-system Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart © Gurdev Singh 2007 Errors can occur at each entity and in each interaction between them in this micro-system And of the:

26 G and R Singh 2001 Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Medication Error Reporting Cascade Consequences Errors ContributorsStory

27 G and R Singh 2001 Click where the error occurred Cascade Consequences Errors ContributorsStory Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart

28 G and R Singh 2001 From the list, select the Error that occurred Cascade Consequences Errors ContributorsStory Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Error: Wrong patient Wrong medication Wrong dose Wrong frequency Wrong route Wrong # of doses Wrong #of refills

29 G and R Singh 2001 From the list, select the Error that occurred Cascade Consequences Errors ContributorsStory Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Error: Wrong patient Wrong medication Wrong dose Wrong frequency Wrong route Wrong # of doses Wrong #of refills Wrong dose

30 G and R Singh 2001 Contributing factors for Error: Wrong dose Click on the place where a Contributor occurred Cascade Consequences Errors Contributors Story Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart

31 G and R Singh 2001 Contributing factors for Error: Wrong dose Select the Contributor from the list Cascade Consequences Errors Contributors Story Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Contributor: Missing/inaccurate information: Weight Allergies Prescription meds OTC meds Past medical history / Problem list Lab values Consult reports Phone messages Poor chart design: Problem list Medication list Allergy list ….

32 G and R Singh 2001 Contributing factors for Error: Wrong dose Select the Contributor from the list Cascade Consequences Errors Contributors Story Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Contributor: Missing/inaccurate information: Weight Allergies Prescription meds OTC meds Past medical history / Problem list Lab values Consult reports Phone messages Poor chart design: Problem list Medication list Allergy list …. Consult reports

33 G and R Singh 2001 Cascade Consequences Errors Contributors Story Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Contributing factors for Error: Wrong dose Click on the place where a Contributor occurred

34 G and R Singh 2001 Cascade Consequences Errors Contributors Story Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Contributor: Missing info from patient: Allergies Prescription meds OTC meds Prescriptions / changes by other providers Past medical history …. Contributing factors for Error: Wrong dose Select the Contributor from the list

35 G and R Singh 2001 Cascade Consequences Errors Contributors Story Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Contributor: Missing info from patient: Allergies Prescription meds OTC meds Prescriptions / changes by other providers Past medical history …. Prescriptions / changes by other providers Contributing factors for Error: Wrong dose Select the Contributor from the list

36 G and R Singh 2001 Cascade Consequences Errors ContributorsStory Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Consequences of Error: Wrong dose Click on the place where a Consequence occurred

37 G and R Singh 2001 Cascade Consequences Errors ContributorsStory Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Consequence: Missed medication Under-medication Over-medication Medication side effects …. Consequences of Error: Wrong dose Select the Consequence from the list

38 G and R Singh 2001 Cascade Consequences Errors ContributorsStory Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Select Consequence: Missed medication Under-medication Over-medication Medication side effects …. Consequences of Error: Wrong dose Select the Consequence from the list Over-medication

39 G and R Singh 2001 Cascade Consequences Errors ContributorsStory Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Consequences of Error: Wrong dose Click on the severity level Severity Severity Level 1. Mild 2.Moderate 3.Severe 4. Fatal ….

40 G and R Singh 2001 Cascade Consequences Errors Contributors Story Patient/ Caregiver Script Office Patient/ Caregiver Medication Home Pharmacist Patient/ Caregiver Pharmacy Nurse Doc Recept. Lab Phone/Fax Chart Consequences of Error: Wrong dose Please give a brief story Severity The story A 48yr old AA male with HTN and angina came today with dizziness. His BP is 90/55. It turns out that 2 months ago his cardiologist started Imdur for angina and cut down his lisinopril from 20mg to 10mg because his BP was on the low side. We didn’t know about the change. 1 month ago the patient called us for a refill of his lisinopril and we called in 20mg.

41 Special Reporting Tools to aid System Improvements Singh: April 2005

42 R & G Singh: Aug. 2002

43 SAFETY JOURNAL System-Based Practice Practice-Based Learning SUNY at Buffalo Leads to Appreciation and Understanding of the System Leads to Appreciation and Understanding of the Curriculum Possible strategies to prevent recurrence (Focus on eliminating latent failures and creating safety barriers, especially “strong” ones Safety Journal Type of Incident (circle):*Observed Error Near Miss Anticipated Error Describe in detail what happened. Do not use dates or names of people or places. In your description be sure to include the following, where relevant:  how the error happened  the consequences of the error and how the error/consequences were detected  details of any special circumstances that contributed  the roles played by individuals, teams, and leadership  details of the systems that were in place and how they contributed to and/or mitigated the effects of the error Distracted by grandchildren Missing Barrier: No mechanism to limit the dose of Regular insulin Both pens look the same Patient picked up wrong pen 1.Make the pens look different e.g. make the Regular pen RED so it stands out 2.Set a maximum dose on the Regular insulin pen, e.g. 12 units 3.Give patients clear instructions regarding what to do if they accidentally overdose 56yr-old female with Type 2 DM on insulin came on to the ER after an accidental overdose of Regular insulin. She takes 30 units NPH with 8units Regular before breakfast. Both types of insulin come in a pen with a dial to set the insulin dose. Both pens look the same. She was at home that morning getting ready to take her insulin when she accidentally picked up the Regular pen and gave herself 30 units of Regular. She realized her mistake right away and so she came to the ER. CONTINUED………… Micro-System: examples The “Story” This makes an excellent Reporting Tool that stimulates Systemic Improvements by aiding Root Case Analysis

44 Journal for Reporting Transition Events -To and from Office- Patient Transferred from our Office to another Health Care Setting Patient/ Caregiver Doc Recept. Nurse Instructions: Write the story on the reverse side. Do not use dates or names. Mark the problems that occurred during the transition. Make any comments in the space provided. If you need more space then use the reverse side. Make sure you use the appropriate side, i.e. Left or Right side. S tatus/Reason for transfer or consult Symptoms Missing Unclear Incorrect Findings Missing Unclear incorrect Action taken Missing Unclear incorrect B ackground Information Problem List Missing Unclear incorrect Medication list Missing Unclear incorrect Allergies Missing Unclear incorrect HCP/DNR Missing Unclear incorrect Emergency tel. contact not provided A ssessment of the problem Missing Unclear R ecommendation Missing Unclear M ode of Communication Phone Delayed Failed Unavailable Missing Fax Delayed Failed Unavailable Missing Delayed Failed Unavailable Missing US Mail Delayed Failed Unavailable Missing Hand carr. Delayed Failed Unavailable Missing Electronic data exchange Delayed Failed Unavailable Missing Misidentification of Patient Patient (family) not given appropriate information The other setting did not seek clarification We were unable to clarify questions from the other setting OTHER……… To ? ( e.g. Hospital, Specialist.) … Content ( S B A R) Story and Remarks/suggestions: P R O C E S S Office Last Four Digits of Your SS# MR# ©ARG Singh’07 Mark the one/s that apply/ies S tatus/Reason for admission or consult Symptoms Missing Unclear incorrect Findings Missing Unclear incorrect B ackground Information Problem List Missing Unclear incorrect Medication list Missing Unclear incorrect Allergies Missing Unclear incorrect HCP/DNR Missing Unclear incorrect Emergency tel. contact not provided A ssessment of the problem Missing Unclear R ecommendation/Action taken Missing Unclear M ode of Communication (D/C summary) Phone Delayed Failed Unavailable Missing Fax Delayed Failed Unavailable Missing Delayed Failed Unavailable Missing US Mail Delayed Failed Unavailable Missing Hand carr. Delayed Failed Unavailable Missing Electronic data exchang Delayed Failed Unavailable Missing Misidentification of Patient Patient (family) not given appropriate information Entry of Info into Office EMR Missing Erroneous Clarifying info is not sought by our office Discharging setting is unable to clarify inquiry OTHER …… Patient Discharged from another Health Care Setting to our Office EMR From? ( e.g. Hospital, Specialist.)…. Content ( S B A R) Story and Remarks/suggestions: P R O C E S S Mark the one/s that apply/ies

45 Our Aspiration Reporting and Taxonomy Transfer approach across all the domains Developing EHR based quality enhancing tools that are useful for health care workers at the point of care and for policy makers at regional, national and international levels Road Map Initiative/AHRQ 2007/NLM USNHII


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