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Innovative Techniques for Physicians to Improve Safety

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Vaginal wet mount microscopy. What's required? Policy- scope of testing for physicians ... Forgotten 'frontline worker' Physician sharps injuries under ... – PowerPoint PPT presentation

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Title: Innovative Techniques for Physicians to Improve Safety


1
Innovative Techniques for Physicians to Improve
Safety
  • Tammy Lundstrom, MD
  • Detroit Medical Center-Wayne State University
  • VP, Chief Quality and Safety Officer

2
Improving Patient Safetymeans . . .
  • Reducing medical errors.

Reducing patient harm.
3
Patient Safety Terminology
4
Overview of a Comprehensive Program
5
Detroit Medical Center
  • 13,000 employees
  • 3000 physicians
  • 1000 Graduate Medical Residents
  • 1000 Medical Students
  • Nursing Students
  • Pharmacy Students
  • PA Students

6
Demonstration of Leadership Support
  • Name of System Quality Council changed to System
    Quality-Medical Safety Council
  • Chief Medical Safety Officer named
  • Medical Safety Committee Established
  • Monthly reports to the Board
  • Medical Safety Plan Developed

7
Value of a Comprehensive Program
  • Reduce fear of reporting errors/near misses,
    gather more data
  • Reduce errors through tracking,
    trending,analysis, and targeted improvement
    projects
  • Reduce errors through prevention

8
Comprehensive Program
9
First Steps
  • Common definitions agreed upon
  • Common database to enter events
  • Information flows through each site Leadership
    and Performance Improvement Committee
  • Information flows from site to system
  • Critical aspects of safety agreed upon

10
What is a Safety Culture
  • And how is it achieved?

11
Lessons from a Leader
  • Safety is not a priority, its a way of life
  • Paul ONeill
  • CEO Alcoa Steel
  • Treasury Secretary

12
Safety Culture Involves Paradigm Shift
  • OLD
  • Who did it?
  • Focus on bad event
  • -Root Cause
  • Top down
  • Punish bad behavior
  • NEW
  • What happened?
  • Focus on Near Miss
  • -FMEA
  • Bottom up
  • Fix broken processes

13
Advantage to Focus on near Misses
  • No patient harm, therefore no blame
  • No guilt
  • Focus on prevention
  • No fear of litigation

14
Disclosure of Unanticipated Outcomes to Patients
and Families
15
What is an Unanticipated Outcome?
  • A negative or unexpected result stemming from
  • A diagnostic test, medical judgment or treatment,
    surgical intervention, or (commission)
  • The failure to perform a necessary test,
    treatment , or intervention (omission)

16
Why Disclosure?
  • We are our patients advocates
  • Literature shows that after an unanticipated
    outcome, the patient and family want to know
    honestly what happened, and how the hospital is
    going to prevent future events
  • Rebuilds trust
  • Caregiver/Doctor relationship

17
Advocating Disclosure
  • American Society for Healthcare Risk Managers
  • JCAHO
  • AHA
  • AMA

18
JCAHO
  • Standard
  • RI.1.2.2 Patients and, when appropriate, their
    families are informed about the outcomes of care,
    including unanticipated outcomes.

19
AHA
  • Develop an institutional policy or position
    statement on disclosure of unanticipated outcomes
  • Differentiate between disclosure of an
    unanticipated outcome and an admission of
    liability
  • Determine who will be responsible for informing
    the patient, and, where appropriate, the family
    and/or legal representative, about the
    unanticipated outcome.
  • Educate caregivers and staff about your
    organizations policies and procedures covering
    this issue, and consider communications training
    for those charged with disclosing unanticipated
    outcomes
  • Specify documentation requirements regarding
    disclosure

20
ASHRM
  • Each Healthcare institution must develop its own
    policy on management of unanticipated outcomes
  • Disclosure of such information to patients and
    families must reflect the requirements of
    applicable law
  • Differentiate between unanticipated outcome and
    admission of liability

21
For additional detail on implementation of a
policy on disclosure of outcomes, consistent with
the requirements of this standard
22
AMA
  • AMA Professional Code of Ethics

23
Steps to Follow After Event
  • Care for immediate needs of patient
  • Preserve evidence (Medical equipment)
  • Document in the medical record
  • Report (Risk Management)
  • Disclose

24
Documentation
  • Document only the facts of what occurred and
    treatment rendered
  • NOT
  • Blame
  • Subjective feelings, opinions
  • Speculation
  • Reference to Incident report

25
Incident Report
  • Complete and submit
  • Notify Risk Management
  • FDA notification if Medical Device or Medication
  • Begin Root Cause/Intensive analysis to examine
    process changes that may prevent future events

26
Who Will Inform the patient?
  • The attending physician
  • May need pre-disclosure conference with Nursing,
    Risk Management
  • All patient questions should be referred to the
    attending physician

27
When Should Disclosure Occur?
  • As soon as possible after immediate needs of
    patient addressed
  • Gather facts FIRST
  • May not have all the facts yet, in which case
    DONT SPECULATE! Offer to speak again as facts
    become known

28
How?
  • Convey compassion
  • I am sorry for your.. I am sorry that you
  • Known facts
  • Privacy
  • No BLAME on any member of healthcare team
  • Avoid defensive posture/reaction
  • Respond to patient complaints (provide forms,
    contact patient advocates/ombudsman)

29
Health Care Worker Involved in Error
  • AVOID BLAME
  • Provide counseling, if needed
  • Remember No one goes to work intending to make a
    mistake
  • HCW feel tremendous guilt after event that harms
    patient

30
Examples from the Front Lines
  • Physician Leadership is Key

31
Medication Safety
  • Why physicians?

32
Medication Safety
  • Large medication errors due to prescribing
    (20-49)
  • For the most part- physicians prescribe
  • DMC Medication Safety Committee
  • Physician Chair
  • Review all events
  • Review ISMP alerts/External incidents
  • Chemotherapy Administration Policy

33
Medication Safety- Physician Lead PI
  • Look-alike Sound-alike Posters and alerts
  • Define safe medication order writing
    policy/pocket card
  • Promote physician incident entry
  • Develop delineation of privileges form related to
    chemotherapy administration

34
(No Transcript)
35
Physician Education
  • Physician Led

36
Board Support
  • All physicians and trainees will have 3 hours of
    mandated compliance and safety education each
    credentialing cycle
  • Failure to complete required education will be
    deemed voluntary resignation
  • Web-based
  • Continuing Medical Education credits
  • Required for all new applications to the Medical
    Staff
  • Physician experts develop and approve education
    modules

37
Physician Education Modules
  • Sexual Harassment
  • Code of Conduct
  • Pain Management
  • Medical Safety and Incident Reporting
  • Restraint Use
  • Conscious Sedation
  • Infection Control
  • Life Safety

38
  • Moderate Sedation
  • for Physicians and
  • Licensed Independent Practitioners

39
Moderate Sedation
  • Moderate sedation/analgesia describes a
    drug-induced depression of consciousness during
    which patients respond purposefully to verbal
    commands, either alone or accompanied by light
    tactile stimulation. No interventions are
    required to maintain a patent airway, and
    spontaneous ventilation is adequate.
    Cardiovascular function is usually maintained.

40
Moderate Sedation Patient Evaluation Standards
  • History and Physical includes
  • abnormalities of major organ systems with
    specific focus on the cardiopulmonary history
  • pregnancy status
  • previous adverse experiences with
    sedation/analgesia, as well as anesthetic
    techniques
  • current medications and drug allergies/adverse
    reactions
  • time and nature of last oral intake of foods,
    fluids, etc.
  • history of tobacco, alcohol, or substance use or
    abuse

41
Moderate Sedation Patient Evaluation Standards
  • Focused physical exam that minimally includes an
    evaluation of the airway and auscultation of the
    heart and lungs.
  • Assignment of ASA Classification of Physical
    Status
  • Pre-procedure laboratory and diagnositic testing
    guided by the patients underlying medical
    condition.
  • History and physical examination are valid up to
    30 days prior to the scheduled procedure.
    Verification and review of this information is
    necessary immediately prior to the provision of
    moderate sedation.

42
Moderate Sedation Monitoring Standards
  • Level of consciousness
  • Monitoring the patients response to verbal
    and/or tactile stimuli should be routine (unless
    contraindicated by procedure).
  • Pulmonary Ventilation
  • Ventilatory function is continually monitored by
    observation and/or auscultation during the
    procedure.
  • Oxygenation
  • Continuously monitored by pulse oximetry with
    appropriate low limit alarms.
  • Hemodynamics
  • Baseline blood pressure established measured at
    regular intervals intra and post-procedure.
    Electrocardiograph continuously monitored.

43
Moderate SedationEmergency Equipment
  • Pharmacologic Antagonists and resuscitation drugs
  • Intravenous access
  • Supplemental oxygen
  • Advanced airway equipment
  • Cardiac defibrillator

44
Moderate SedationDischarge Criteria
  • Following the provision of moderate sedation,
    patients are monitored until they are suitable
    for discharge
  • Level of consciousness and hemodynamic/respiratory
    variables evaluated and no longer at risk for
    sedation and cardiorespiratory depression.
  • For patients who received pharmacologic
    antagonists, post-procedure monitoring should
    continue for a sufficient period of time to
    detect and appropriately treat its recurrence.
  • Discharge criteria that pertain to the patient
    population and specific procedures is developed
  • A qualified physician or registered nurse should
    be in attendance until discharge criteria are
    fulfilled.

45
Sharps Safety
  • Why Physicians?

46
Physician-Performed TestingRequirements
  • Dfn Test personally performed by a physician in
    conjunction with the physical examination or
    treatment of a patient

47
PPT
  • Amniotic fluid pH
  • Cervical mucous smears for ferning
  • Fecal leukocytes
  • Gastric biopsy urease
  • Nasal smears for eosinophilia
  • Occult blood, fecal and gastric
  • Pinworm exam

48
PPT
  • Post-coital mucous exam
  • Potassium hydroxide preparations
  • Semen analysis, qualitative
  • Synovial fluid for crystals
  • Urine dipstick
  • Urine sediment microscopy
  • Vaginal wet mount microscopy

49
Whats required?
  • Policy- scope of testing for physicians
  • Procedure manual- specimen handling
  • QI program
  • Quality control, reagents
  • Instrument maintenance
  • Corrective action equipment/reagent failure
  • Documented training- test specific
  • Competency assessment-credentialing
  • System for reporting results

50
How will you comply?
  • Training and documentation
  • Reagent control
  • No bottles in pockets!!
  • House staff? Other trainees?

51
Sharps Safety
  • Physicians perform many procedures
  • Forgotten frontline worker
  • Physician sharps injuries under-reported
  • HIV conversions
  • 57 documented conversions
  • 6 physicians
  • Many Safety devices used primarily by physicians
  • Safety Scalpels
  • Blunted suture needles

52
Physician Peer review and Patient Safety
53
Incident Reports
Incident Occurs
Peer Review -Physician specific practice as it
relates to care of this patient
Root Cause -Process
54
Goal of Peer Review
  • Monitor and improve physician care of patients
  • Accomplish by
  • Open, non-punitive discussion
  • Review and discuss alternatives
  • Disseminate to ALL physicians
  • Monthly Vignettes

55
Code Blue
  • Get away from monitoring Code
  • Move towards review previous 48 hour record
  • Could this event have been prevented?
  • Were signs of deterioration missed?
  • Elevated BP, dropping BP
  • Elevated HR, dropping HR
  • Elevated RR
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