Title: Innovative Techniques for Physicians to Improve Safety
1Innovative Techniques for Physicians to Improve
Safety
- Tammy Lundstrom, MD
- Detroit Medical Center-Wayne State University
- VP, Chief Quality and Safety Officer
2Improving Patient Safetymeans . . .
Reducing patient harm.
3Patient Safety Terminology
4Overview of a Comprehensive Program
5Detroit Medical Center
- 13,000 employees
- 3000 physicians
- 1000 Graduate Medical Residents
- 1000 Medical Students
- Nursing Students
- Pharmacy Students
- PA Students
6Demonstration 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
7Value 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
8Comprehensive Program
9First 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
10What is a Safety Culture
11Lessons from a Leader
- Safety is not a priority, its a way of life
- Paul ONeill
- CEO Alcoa Steel
- Treasury Secretary
12Safety 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
13Advantage to Focus on near Misses
- No patient harm, therefore no blame
- No guilt
- Focus on prevention
- No fear of litigation
14Disclosure of Unanticipated Outcomes to Patients
and Families
15What 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)
16Why 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
17Advocating Disclosure
- American Society for Healthcare Risk Managers
- JCAHO
- AHA
- AMA
18JCAHO
- Standard
- RI.1.2.2 Patients and, when appropriate, their
families are informed about the outcomes of care,
including unanticipated outcomes.
19AHA
- 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
20ASHRM
- 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
21For additional detail on implementation of a
policy on disclosure of outcomes, consistent with
the requirements of this standard
22AMA
- AMA Professional Code of Ethics
23Steps to Follow After Event
- Care for immediate needs of patient
- Preserve evidence (Medical equipment)
- Document in the medical record
- Report (Risk Management)
- Disclose
24Documentation
- Document only the facts of what occurred and
treatment rendered - NOT
- Blame
- Subjective feelings, opinions
- Speculation
- Reference to Incident report
25Incident 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
26Who 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
27When 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
28How?
- 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)
29Health 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
30Examples from the Front Lines
- Physician Leadership is Key
31Medication Safety
32Medication 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
33Medication 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)
35Physician Education
36Board 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
37Physician 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
39Moderate 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.
40Moderate 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
41Moderate 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.
42Moderate 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.
43Moderate SedationEmergency Equipment
- Pharmacologic Antagonists and resuscitation drugs
- Intravenous access
- Supplemental oxygen
- Advanced airway equipment
- Cardiac defibrillator
44Moderate 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.
45Sharps Safety
46Physician-Performed TestingRequirements
- Dfn Test personally performed by a physician in
conjunction with the physical examination or
treatment of a patient
47PPT
- Amniotic fluid pH
- Cervical mucous smears for ferning
- Fecal leukocytes
- Gastric biopsy urease
- Nasal smears for eosinophilia
- Occult blood, fecal and gastric
- Pinworm exam
48PPT
- Post-coital mucous exam
- Potassium hydroxide preparations
- Semen analysis, qualitative
- Synovial fluid for crystals
- Urine dipstick
- Urine sediment microscopy
- Vaginal wet mount microscopy
49Whats 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
50How will you comply?
- Training and documentation
- Reagent control
- No bottles in pockets!!
- House staff? Other trainees?
51Sharps 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
52Physician Peer review and Patient Safety
53Incident Reports
Incident Occurs
Peer Review -Physician specific practice as it
relates to care of this patient
Root Cause -Process
54Goal 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
55Code 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