1. August 5 2014 VCU INTERNAL MEDICINE MORBIDITY AND MORTALITY

2.  https://www.youtube.com/watch?v=xsy5Jr3y8 LA https://www.youtube.com/watch?v=xsy5Jr3y8 LA

3. PATIENT SAFETY  To discuss medical errors leading to adverse events in a systems based fashion.  To increase understanding of the errors that occur in medicine on an individual level.  To educate on when and how to disclose medical errors to patients.  To discuss medical error in the medico-legal context including steps which can reduce the chance of malpractice.  To create projects for risk reduction and error prevention. Ethan Cumbler, MD MedEd Portal

4. WHAT IS AN ADVERSE EVENT?

5. ADVERSE EVENT An unintentional, definable injury resulted from a medical intervention (ie not from the disease process.)

6. WHAT IS A MEDICAL ERROR ?

7. MEDICAL ERROR Failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning.) Reason, 1990 Human Error

8. SYSTEMS THINKING  Errors in thinking have been recognized by the field of cognitive psychology to be a product of normally adaptive mental processes thus will occur in predictable circumstances  Recognize that errors which occur at the “sharp end” are a frequently influenced by pressures remote from the final accident.  Typically for an adverse event to occur as a result of an error multiple mistakes need to have happened at different levels of the system. Many of these are “latent errors” which have been present for some time.  Good systems reduce the possibility of individual mistakes leading to harm “forced function”

9. REDUNDANCY  Remember that redundancy alone does not create safety.  In “An Experimental Study in Nurse-Physician Relationships” 22 nurses received a call from an unknown doctor with an order to give 20mg of “Astrogen” immediately so it would have taken effect by his arrival. The label on the bottle indicated 10mg was the maximum dose. How many gave the drug?

10. ANSWER  21 out of the 22 nurses gave the twice maximum dose as ordered.  Is that a product of the 1960s…. or does this still happen?

11. HOW CAN WE ANALYZE MEDIAL ERROR WITH A NEW FOCUS ON SYSTEMS?  Each M&M will incorporate small didactic features focused on one of the elements surrounding medical error  Systems  Cognitive Errors and Heuristics  Root Cause Analysis  Disclosure and Apology

12. 1.Adverse event? Medical Error? Causation? 2.Did Systems Errors contribute? Which types? 3.Did Individual or Cognitive Errors contribute? Which types? 4.List Heuristic Failures leading to Individual Errors 5.What level of harm came to the patient? 6.What would you disclose? 6 STEPS TO CASE ANALYSIS

13.  Discuss systems and individual issues creating barriers to delivery of patient care  Help improve patient care  Not to place blame or say who was at fault  If you were involved with this case, please do not state your involvement in the case GOALS

14.  Identify a case where there was a bad outcome, perhaps related to systems issues or human error.  Review the case.  Break into groups  Small group brainstorm – why did things go wrong?  Small groups present their findings in a large group discussion.  Important to leave with root causes and possible solutions FORMAT

15.  Level of care assignment at the VA  Escalation  MICU consultation at the VA KEY ISSUES

16.  64 yo Veteran  PMHx of ETOH abuse and ETOH cirrhosis  1 day hx of dizziness and multiple falls, esp when going from seated to standing position  Has fallen 7-8 times but denies LOC  No fevers, chills, nausea, vomiting, or hematemesis  Denies melena or hematochezia  Poor po intake HISTORY – ADMIT NOTE

17.  No increasing abd girth but does note aching over RLQ  Wife notes increasing confusion  Has been prescribed diuretics and lactulose but does not take them  Continues to drink- last drink on morning of admission HISTORY – ADMIT NOTE

18. PMHx  Alcohol abuse  Alcoholic cirrhosis  Tobacco abuse  Chronic sinusitis  Knee pain  Anemia- folic acid deficiency Meds– not taking  Furosemide 20mg daily  Omeprazole 20mg po daily HISTORY- PMHX, MEDS

19. SHx: Retired lawyer Lives with wife Smokes pipes Drinks 3-6oz Irish whisky daily Denies illicit drugs FHx: none HISTORY- SHX, FHX

20.  PE:  VS –BP 78/50  99/71 after 2L IVF, P 80, R 17, T 97  Gen- NAD, lying in bed  HEENT- anicteric, PERRL, EOMI, spider angiomata on forehead  CV- regular rhythm, nl S1S2, no S3S4, III/VI holosystolic murmur at LLSB rad to axilla, no rub or gallop  Pulmo- non-labored. Mild gynecomastia.  Abd – soft, nl BS, NTND, no fluid wave. Pt refused rectal  MSK- No edema. FROM. No joint swelling  Neuro – AAO x 4. No asterixis. Dysmetria. Abnl finger to nose  Psych – flat affect, cooperative PE ON ADMISSION

21.  Na 143, K 3.9,Cl 109, CO2 14, BUN 15/cr 1.78  Hgb 7.2 (MCV 90), WBC 8.7, Plt 162 (prev Hgb 12-13)  Alb 2.6, AST 190, ALT 43, ALP 104, TB 1.6  CPK 111  INR 2.0  Lactate 10.2  LDH389, haptoglobin 30.7  Head CT- no intracranial hemorrhage or mass. Moderate generalized cortical atrophy. ADMIT LABS, STUDIES

22.  Hypotension- ddx includes sepsis vs GI bleed vs dehydration vs adrenal insufficiency. Less likely but still in ddx includes PE, decompensated cirrhosis or valvulopathy.  UA, CXR and blood and urine cx  UDS  Am cortisol  TTE  Serial CBC, type and screen, transfuse if <7 A/P

23.  Anion-gap metabolic acidosis– likely from lactic acidosis from hypotension  IVF  Trend lactate  AKI- prerenal vs ATN secondary to hypotension  IVF, UA and urine cx pending  Acute on chronic anemia- Hgb 7.2 from baseline 12. Evidence of hemolysis (high LDH, low normal haptoglobin, evidence of schistocytes on smear.) Hx of stage 1 varices but no description of bleed  Serial CBC, type and screen, start PPI A/P - ADMIT

24.  Falls- likely from hypotension- IVF  ETOH abuse- CIWA scoring, prn ativan  Cirrhosis- MELD 21 A/P - ADMIT

25. “…did fall on left side and has large abd/flank bruise. No fevers, chills, chest pain, seizure activity. Initially hypotensive but improved with 3.5L fluids and receiving 2u PRBC. On exam…bruise on left flank. Abdomen obese but not distended, no fluid wave. Another bruise noted on left lateral thigh but has good ROM and strength. FOBT neg but minimal stool in vault so poor sample.” RESIDENT ADDENDUM

26. “Hgb dropped to 5.7 with fluid resuscitation. Lactate improving- 10.2  8.9. Will consult GI for possible EGD, keep NPO. IV pantoprazole RESIDENT ADDENDUM

27.  New, moderate-sized intermediate density hemorrhagic ascites in perihepatic, perisplenic and paracolic gutter  Diffuse mesenteric stranding  Mild lobulation at tip of spleen suggesting source of bleed is from left flank. Spleen most likely source of the bleeding which may or may not have already stopped.  Splenic and mesenteric varices ABD CT

28.  Gen surg consulted- correct coagulopathy, transfuse, stat CTA…”May require transfer to MCV for management of traumatic injuries if CTA reveals significant pathology.”  Gen med attending-  Grey Turner’s sign on abdomen…Lipase 500 but pt has no nausea or vomiting to go along with dx of hemorrhagic pancreatitis.  MICU consulted and pt transferred DAY 2

29.  DDx- spontaneous retroperitoneal bleed vs traumatic bleed from falls  8 day hospital course  Repeat CT- progression of abdominal hemorrhagic ascites  Developed increased abd distension, tense ascites with decreased urine output. Concern for abdominal compartment syndrome  Paracentesis performed (5.5L hemorrhagic ascites) to relieve pressure HOSPITAL COURSE

30.  Multiple angiographies not able to locate source of bleed  Gen surg- Not candidate for ex lap as pt with high risk for intraoperative mortality  14u PRBC, 12U FFP, 1 dose cryoprecipitate  Hepatology – not candidate for TIPS, management options limited  Discharged to home with home hospice HOSPITAL COURSE

31. SMALL GROUP DISCUSSIONS Modified Root Cause Analysis

32.  Level of care assignment at the VA  Escalation  MICU consultation at the VA KEY ISSUES

33. 1.Adverse event? Medical Error? Causation? 2.Did Systems Errors contribute? Which types? 3.Did Individual or Cognitive Errors contribute? Which types? 4.List Heuristic Failures leading to Individual Errors 5.What level of harm came to the patient? 6.What would you disclose? 6 STEPS TO CASE ANALYSIS

34. LARGE GROUP DISCUSSION  Was there a medical error in the adverse event that occurred in today’s discussion? Was that error preventable?  What were the health system forces that contributed to the error? How can those systems be changed to prevent a similar adverse event from occurring in the future?

35. LARGE GROUP DISCUSSION  Was there a cognitive error that contributed to the error? How would you address the cognitive error?  Please recommend one course of action that our institution can take to prevent an event like this in the future. Who else should be involved in this process? What would be the role of the residents and students?