1. Four Actions The Hospitalist’s Role in Patient Safety Mark B. Reid, MD Division of Hospital Medicine Denver Health Medical Center University of Colorado: GIM TMC February 17, 2009 Denver VA Hospital

2. To Err is Human: 1999 The flawed assumptions  Safety results from complexity  Errors are caused by bad people  This problem will be easy to fix

3. What has Worked? 1.Regulation: JCAHO 2.Reporting 3.Teamwork Training 4.IT The End of the Beginning: Patient Safety Eight Years After the IOM Report on Medical Errors. Robert M. Wachter, MD, 12 th Annual Management of the Hospitalized Patient, San Francisco, CA October 23, 2008

4. Learning Objectives 1. Know when to wash your hands 2. Know who to call when an error occurs 3. Name one intimidating behavior 4. Name a common CPOE error

5. ACTIONS 1. Do JCAHO 2. Report errors 3. Be available 4. Beware computer errors

6. 1. When rounding on your patients, you foam or wash your hands: A) never B) before each patient C) after each patient D) whenever someone is watching E) before and after each patient

8. What has Worked? 1.Regulation: JCAHO = rules 2.Reporting 3.Teamwork Training 4.IT

9. Hand Hygiene Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16) Donskey and Eckstein 360 (3): e3, Figure 1 January 15, 2009

10. # Washes ≥ [# Patients] + 1

11. Practical Script for Hand Hygiene (hand washes are green arrows) Time Answer phone P1 Check labs P2P3 P4P5

13. Do JCAHO National Patient Safety Goals: 2009 Correctly identify patients Read back telephone orders “Do not use” abbreviations Critical values Standardized “hand-offs” Look-alike/sound-alike drugs Wash your hands Reconcile medications @ admit and D/C Identify patients at risk for suicide Mark site/time out Action 1

14. 2. A patient is transferred to the floor from the MICU after a Tylenol overdose. What special step(s) should you take? A) speak directly to the psychiatry consultant B) confirm that patient has a mental health hold C) assign patient to a sitter room D) check his bag E) all of the above

16. What has Worked? 1.Regulation: JCAHO = rules 2.Reporting 3.Teamwork Training 4.IT

17. The Promise of Error Reporting: Safety in Air Travel

18. Joint Commission: National Patient Safety Goals

19. JCAHO Root Cause Analysis Hospitals obliged to report events to JCAHO 42 reports covering “the worst” errors: PCA by proxy, delays in treatment, prevention of ventilator associated death Example: 675 inpatient suicides reported as sentinel events Sentinel Event Alert: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/ http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/

20. JCAHO Root Cause Analysis: Inpatient Suicide Incomplete suicide risk assessment at intake Failure to identify a contraband Incomplete communication among caregivers. Assignment of the patient to an inappropriate unit or location

21. The case of the pills in the bag

22. Report Errors Call Risk Management for “Never Events” Wrong side/site surgery Air embolism Patient suicide Death from medication error Death from hypoglycemia (<60) Stage 3 or 4 pressure ulcer Death or severe disability from a fall National Quality Forum Serious Reportable Events in Healthcare 2006 Update Action 2

23. 3. A nurse tells you he noticed a patient was unsteady on her feet. The way you respond to this information could save another patient’s life. A) yes B) no

25. What has Worked? 1.Regulation: JCAHO = rules 2.Reporting 3.Teamwork Training 4.IT

26. Crashing Flight Simulators

27. JCAHO

28. Behaviors that Undermine a Culture of Safety Intimidating and disruptive behaviors can foster medical errors Staff within institutions often perceive that powerful, revenue-generating physicians are “let off the hook” A few commit many but many commit a few http://www.jointcommission.org/SentinelEvents/SentinelEventsAlert/sea_40.htm

29. Are You an Intimidator?  Reluctance or refusal to answer questions, return phone calls or pages  Use of condescending language or voice intonation  Impatience with questions  Verbal outbursts or physical threats

30. TEAMWORK Sutker, James Baylor Medical Grand Rounds, 7/17/2007

31. “Thanks for letting me know. That is very important information. You should always feel free to tell me when you notice anything.” The Correct Response to the Nurse

32. Be Available Listen and respect staff opinions Be approachable and available Don’t be an intimidator Action 3

33. 4. Do computers increase safety? A) yes B) no

35. What has Worked? 1.Regulation: JCAHO = rules 2.Reporting 3.Teamwork Training 4.IT

36. New Errors in CPOE

37. Sutker, James Baylor Medical Grand Rounds, 7/17/2007 1.Wrong patient selected 2.Loss of chart personality 3.Warning desensitization 4.Order set ignorance

38. Beware Computer Errors 1. Is this the right patient? 2. Look up drug doses, especially for infrequently used medicines 3. Be redundant—talk to a human being! Action 4

39. Learning Objectives 1. Know when to wash your hands 2. Know who to call when an error occurs 3. Name one intimidating behavior 4. Name a common CPOE error Did you learn anything?

40. ACTIONS 1. Do JCAHO 2. Report errors 3. Be available 4. Beware computer errors

41. Questions?