Patient Safety and Medical Error

1
Patient Safety and Medical Error

• Holly J. Humphrey, MD
• Dean for Medical Education
• The University of Chicago Pritzker School of
  Medicine

2
The Institute of Medicine Quality Initiative

• To Err Is Human Building a Safer Health System
  (Released November, 1999)
• Impact?
• Awareness
• Regulation
• Reporting Systems
• Information Technology
• Recognition that medical errors are not usually
  the fault of a single person but are usually the
  result of flawed systems (Leape, Berwick, JAMA,
  2005).

3
The Physician Charter

• Published by the ABIM Foundation, American
  College of Physicians
• and European Federation of Internal Medicine in
  2001.
• Ten professional commitments, including
• Commitment to honesty with patients
• Whenever patients are injured as a consequence
  of medical care,
• patients should be informed promptly because
  failure to do so seriously
• compromises patient and societal trust.
• Commitment to improving quality of care
• Physicians must be dedicated to continuous
  improvement in the quality of
• health care. This commitment entails not only
  maintaining clinical competence
• but also working collaboratively with other
  professionals to reduce medical
• error.

ABIMF, ACP, EFIM 2001
4
Barriers to Change

• Threat to physician autonomy and authority
• Fear of malpractice liability)
• Complexity of health system (mix of specialties,
  subspecialties, allied health professionals,
  reimbursement issues)
• Lack of leadership
• Scarcity of measures to gauge progress

Leape, Berwick, JAMA, 2005
5
Intrinsic Challenge of Medical Education
Safety needs of patients who benefit when being
cared for by the most experienced physician
available
Educational needs of learners who require
increasing independence
Ludmerer, Johns, JAMA, 2005
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Patient Safety and Medical Education
PATIENTS
Interprofessional Teams
Information Systems
SYSTEMS FOCUS
STUDENTS
FACULTY
Lifelong Learning
Humphrey, JGIM, 2005
7
Example

• The University of Chicago
• Hand-Off Clinical Experience

8
Recent focus on Hand-Offs

• July 2003 ACGME set limits for resident duty
  hours
• Reduce sleep deprivation and improve patient
  safety
• Unintended consequence is increase in number of
  hand-offs
• Safety of hand-off
• Error-prone
• Variable
• Vulnerable gap in patient care

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Patient Safety and Medical Education
10
Teaching Hand-Offs

• 90-minute interactive workshop on effective
  hand-off strategies
• Objective Simulated Hand-Off Experience (OSHE)
  performed 7 days after initial workshop
• Students evaluated pre- and post-intervention

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Teaching Hand-Offs

• Complete written sign-out
• Verbally hand-off patient and sign-out to
  standardized resident receiver
• Underwent one hour training on hand-off
  expectations using the case and anticipated
  trigger interval events
• Feedback facilitated using Hand-off CEX
• Domains assessed were organization/efficiency,
  communication skill, clinical judgment,
  professionalism
• Debriefing after OSHE

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Teaching Hand-Offs

• Results
• Statistically significant improvement in
  preparedness for performing effective hand-off
• 12 pre vs. 50 post reporting well-prepared
  (plt0.012)
• Student Comments
• Unanimously positive experience
• a must have, a great experience!
• probably the MOST USEFUL of all topics,
  definitely under-taught
• Felt realistic due to actual resident evaluators
• Wanted training for additional scenarios
• Practice sending and receiving hand-off

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Conclusions

• Feasible interactive mechanism to provide
  students with ability to practice handoff
  communication
• Well-received by both students and resident
  receivers
• Has potential for future evaluative purposes

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Patient Safety and Medical Education