Medical Service Professional’s Role in Improving Patient Safety and Decreasing Organizational Legal Risk November 13, 2015

A patient story… 2 month old Patient underwent surgery to repair closure of ventriculoseptal defect and atrial septal defect. Surgeon inadvertently sutured valve shut. Prognosis is terminal. Initially when report the root cause analysis was conducted and the physician wanted it to remain a peer review issue only due to surgical technique. It was a human error. However, after some discussion and persuasion, the physician agreed to review the case with the team that was in the operating room at the time. Of course, this was a very complex case in a very small body. However, there was a point after the cross clamp was removed from the aorta that the infant failed to have any urinary output. This continued throughout the closure of the procedure, lasting about 45 minutes. While unusual, no one mentioned that there was ZERO “0“ output. This was a signal to the physician that something was wrong with perfusion. This would have prompted a re-look at the closure cavity. Physicians do not work in a vacuum, even though culturally and socially we treat them like they do.

Decreasing Legal Risk Primary source verification Completed appointment forms Sharing previous case history with legal or credentialing committee

Decreasing Legal Risk Normal course of business Hammond v. Saini – NC Supreme Court decision Protecting your documents

Decreasing Legal Risk Peer Review Confidentiality Protection Safety

Decreasing Legal Risk Patient Safety Participating in Root Cause Analysis Encouraging frank safety discussion Risk reduction Regulatory issues Medical Staff bylaws Rules & Regulation Policies

Decreasing Risk Physicians are part of the TEAM! Leadership Ownership They are not the expert in everything

Improving Patient Safety Just Culture Punitive environment Transparency Secrecy Patient Centered Provider Centered Interdependent collaborative, interprofessional teamwork Reliance on independent, individual performance excellence System failures Errors as individual failures

Improving Patient Safety Just Culture Punitive environment Transparency Secrecy Patient Centered Provider Centered Interdependent collaborative, interprofessional teamwork Reliance on independent, individual performance excellence System failures Errors as individual failures

Improving Patient Safety Simulation practice insertions Insertions with supervision Standardize insertion kits Barrier on proximal end to hold it Errors as individual failures System failures

Improving Patient Safety Punitive environment Skill based error – honest mistake Just Culture

Skill based error – honest mistake Punitive environment Just Culture

Improving Patient Safety Secrecy Share the story, peers learn from honest mistakes made from others Transparency

Improving Patient Safety Provider Centered Patient had IO access and fistula Culture is to place CVC during Code Blue Patient Centered

Improving Patient Safety Designate a CVC buddy to assist with procedure and/or to determine that all equipment, including guidewire, is retrieved appropriately following procedure Reliance on independent, individual performance excellence Interdependent collaborative, interprofessional teamwork

Medical Service Professional’s Role in Improving Patient Safety and Decreasing Organizational Legal Risk November 13, 2015