Patient Safety Case Conference Modified M

1
Patient Safety Case Conference/Modified MM
Faculty Development

• John Gosbee
• Ed Dunn
• Craig Renner
• Linda Williams
• John.Gosbee_at_med.va.gov www.patientsafety.gov

2
Location in our VA NCPS Curriculum Toolkit

• Content
• Patient Safety Introduction
• Human Factors Engineering
• Etc

• Instructor Preparation
• Swift and Long Term Trust
• Selling the Curriculum
• Etc

• Alternative Education Formats
• Pt Safety on Rounds (Modulettes)
• Doc-U-Drama
• Patient Safety Case Conference (MM)
• Etc

3
Objectives Modified Case Conferences

• Overview of formats that have promise
• Introduction to tools (poster and handouts)
• Key instructor skills
• Case selection
• Preparation
• Recovery and redirection

4
Where is this being done?

• University of Michigan (many times/year)
• Senior Resident Morning report Sessions
• Facilitators chief med residents and a faculty
  member
• Root causes and countermeasures determined
• Cleveland VA (many times/year)
• Similar to Univ of Michigan
• Modified MM for internal medicine
• Pittsburgh VA and University of Pittsburgh
• Similar to Cleveland, but for Critical Care
  Medicine
• Often times with more than one case aggregated

5
Key Preparation

• Swift Trust
• Tell your stories first
• Avoid saying bad luck or the only time I made
  and error
• Ask what happened?, not who did it?
• Long-term Trust
• Understand how to protect resident
• Make sure you know your VA or university rules
• Make a change, no matter how small, after each
  case

6
Change MM Conferences?

• Similar to changing/enhancing case conferences
• Differences between medical and surgical MMs
• Aggregation of more than one type of case
• Focus on type of vulnerability, not persons
• Forces teacher and learner to sharpen their
  point

7
Key Reading and Preparation

• RCA Triage Booklet and Trainer CD
• Tool to lower hindsight bias, etc
• Proven to work
• More involved, but a great resource
• Dekker S. The Field Guide to Human Error
  Investigation. Burlington, VT Ashgate. 2002.

8
Key Web Sites

• To gather ideas for flow and direction
• Web MM (sponsored by AHRQ)
• www.webmm.ahrq.gov

9
Key Web Sites

• To generate ideas for novel remedies
• www.mistakeproofing.com

10
Key Web Sites

• www.baddesigns.com
• Some medical examples with pictures

11
Case Selection

• Presenter
• They need to Knows a lot about system detail
  (communication, room layout, etc)
• You need to brief them ahead of time (even if 5
  min)
• Discussant/Facilitator
• Knows something about the systems issues..
• Or, works/preps with a patient safety colleague

12
Balance with Professionalism
13
(No Transcript)
14
Morbidity Mortality ConferenceA Forum for
Improving Patient Safety?
15
M M Conference Historical Roots

• Ernest Codman End Results Idea, early 20th
  cent.
• End Result Card annual update (Sx, Dx, Rx plan,
  complications)
• ACS Standards Committee 1916
• Intense opposition from physicians
• Anesthesia Mortality Committee 1935
  Philadelphia
• Multi-institutional review group
• Precursor to M M share knowledge about
  fatalities from anesthesia and other interesting
  anesthetic situations.
• Anesthesia Study Commission 1940
• Expanded to include non-fatal complications
• Included all physicians, residents, and interns

16
Historical tensions inherent in the roots of the
M M conference remain relevant today Need for
Learningv.Fear of Incrimination
17
Codmans concept Improve medical practice by
the examination of experience
18
Cross-sectional Study of MM conferences in 4
hospitals

• Prospective survey of 332 MM conferences in 4
  hospitals (UCSF MC, SF VAMC, SF Gen. Hospital,
  Stanford Univ. MC) 7/2000 to 4/2001
• Internal Medicine 100
• Surgery - 232
• Outcome measure frequency of presentation of
  adverse events, discussion/analysis of patient
  safety issues
• Study conducted by trained physician observors

Pierluissi, R et al. Discussion of Medical
Errors in Morbidity and Mortality Conferences.
JAMA 2003 290 2838-42.
19
Results of MM Survey
Pierluissi et al
20
MM Study Conclusions

• Key cultural differences Medicine v. Surgery
• Surgery present and discuss adverse events but
  overemphasize role of individual and
  underemphasize role of systems in posing
  solutions
• Medicine infreq present adverse events MM more
  an academic/didactic exercise overemphasize role
  of individual
• Similarities between Medicine Surgery
• conference leaders fail to model error
  acknowledgment and link discussion to patient
  safety education and local improvement work
• Both missed opportunities for learning to improve
  patient safety

Pierluissi et al
21
Orlander reported that 80 of 295 responding
Internal Medicine program directors believe that
M M cases were most often selected because of
adverse events or suspected error.(37 in
Pierluissis data)
Orlander, J. et al. The Morbidity and Mortality
Conference The Delicate Nature of Learning from
Error, Acad. Med. 2002771001-1006.
22
(No Transcript)
23
MM Conference Forum for Educational Change

• Only time of the week staff and residents
  assemble in formal interactive session
• Dept clinical knowledge on display debunk
  folklore
• Develops organization and presentation skills
• Venue for testing ideas and educational
  techniques
• Opportunity for integrating systems thinking to
  PC
• Vehicle to implement small team approach to PC
  same skills for hand-offs, cross coverage,
  sign-outs
• No need for high level funding
• Medical student recruitment tool
• Year-long curriculum for entire department
• Enhanced educational value counters restricted
  work hours

24
M M Matrix

• Report events to create a story of what
  occurred
• Report events in a manner that seeks the meaning
  of the story
• Develop recommendations for improvement
• Implement lessons learned
• Track the changes and gauge their effect

Gordon, LA Can Cedars-Sinais M M Matrix save
surgical education? Bulletin of ACS, Vol. 89,
No. 6, June 2004 Need RCA to bridge 2 and 3
25
Next

• Walkthrough a guide book and a documentation card
  for learners (20 min)
• Linda Williams
• Small group exercise (30 min)

26
Patient Safety Case Conference
Step 1
From Who done it?
To What caused it?
27
Patient Safety Case Conference
Step 2

• 65 y.o. - mild chest pain
• R/o MI tests inconclusive
• Transferred via ambulance - increased distress
  unstable angina, possible MI,
  bypass

Noisy environment
Travel distance
New equipment
Training required?
Monitor malfunction?
28
Patient Safety Case Conference
Step 3
29
Patient Safety Case Conference
Assignment Conduct a Patient Safety Case
Conference
Comments and questions will take the discussion
in a direction that will reveal systems issues.
Goal
30
References

• Gosbee JW, Anderson T. Human factors engineering
  design demonstrations can enlighten your RCA
  team. Quality Safety in Health Care. 2003
  12 119-121. http//qhc.bmjjournals.com/cgi/conten
  t/abstract/12/2/119?etoc
• Beauregard MR, Mikulak RJ, McDermott RE. The
  Basics of  Mistake-proofing. 1997. New York
  Quality Resources.
• Dekker S. The Field Guide to Human Error
  Investigation. Burlington, VT Ashgate. 2002.