Preventing Medical Errors in Physical Therapy

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Preventing Medical Errors in Physical Therapy

• Carol A. Clayton, Ph.D., PT

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Objectives

• Identify two historical factors (either federal
  or state) which contributed to this course being
  required.
• List two key conclusions of the IOM report, 1999
• Define Adverse Event, Medical Error, and
  Sentinel Event
• Explain the RCA and FMEA approaches to problem
  solving
• Identify error-prone situations in PT
• Explain the PT/PTAs responsibility for reporting
  medical errors
• Explain why errors happen and how they can be
  prevented in a PT Dept to insure patient safety
  e.g. documentation, communication,
  pharmacological components, contraindications/indi
  cations.
• Describe pros and cons for having a voluntary and
  mandatory reporting system
• Explain the role of the professional associations
  concerning patient safety

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HAVE YOU EVER HEARD SOME ONE SAY

• Hospitals are where you go to die.
• I didnt get better, I got worse.
• I dont think they knew what they were doing!
• I couldnt understand a word she said.
• Get a second opinion!!!
• I wasnt sick until I went into the hospital

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Medical Errors have been going on for a long
time patients and health care workers have known
this most are never reported mistakes have been
buried patients have died from preventable
mistakes.
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• The health care system is NOT a healthy system!
• The scope of medical errors and patient safety
  problems has never been documented before.
• What got the ball rolling to finally take a look
  at the HEALTH CARE SYSTEM?

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HISTORICAL PERSPECTIVE

• Clinton-Gore Administration
• Balance Budget Act of 1997. This was an effort
  to eliminate financial fraud and abuse within
  health care.
• Many budget cuts in spending
• Medicare/Medicaid cuts
• Entitlement was cut
• Treatments limited to minutes
• Caps placed on services
• Gag clauses added

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HISTORICAL PERSPECTIVE

• Clinton-Gore Administration (contd)
• 1997 Advisory Commission on Consumer Protection
  and Quality established. This was an effort to
  improve the quality of health care.

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HISTORICAL PERSPECTIVE

• Clinton-Gore Administration (contd)
• 1998 Quality of Healthcare in America Project
• The Quality Interagency Coordination Task Force
  (QuIC) established to coordinate quality
  improvement activities in Federal health care
  programs
• QuIC included the departments of Health and Human
  Services, Labor, Veterans Affairs, Commerce, and
  Defense the Coast Guard the Bureau of Prisons
  and the Office of Personnel Management.

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HISTORICAL PERSPECTIVE

• Clinton-Gore Administration (contd)
• 1998 Quality of Healthcare in America Project
  (Milestone Study)
• Institutes of Medicine (IOM) became responsible
  for this Project
• Results of IOM study (published in 1999)
  precipitated many more federal and state
  initiatives and received a lot of Media
  attention.

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HISTORICAL PERSPECTIVE

• Clinton-Gore Administration (contd)
• 1999/2000 The Agency for Healthcare Research and
  Quality (AHRQ) charged with supporting research
  designed to improve the quality of health care,
  reduce its cost, improve patient safety, address
  medical errors, and broaden access to essential
  service.

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INSTITUTES OF MEDICINE

• It is the medical arm of the National Academy of
  Sciences.
• Their Project titled Quality of Health Care in
  America
• Focus of project medical errors and patient
  safety

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INSTITUTES OF MEDICINE

• Reasons for this focus
• Errors were responsible for an immense burden of
  patient injury, suffering, and death
• Errors in the provision of health services,
  whether they result in injury or expose the
  patient to the risk of injury, were events that
  everyone agrees just shouldnt happen
• Errors were readily understandable to the
  American public
• There was a sizable body of knowledge and very
  successful experiences in other industries to
  draw upon in tackling the safety problems of the
  health care industry
• The health care delivery system was rapidly
  evolving and undergoing substantial redesign,
  which may introduce improvements, but also new
  hazards.

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INSTITUTES OF MEDICINE

• 1999 published report called To Err is Human.
  Building a Safer Healthcare System
• Results stated 44,000 98,000 people die in
  hospitals each year as a result of preventable
  medical errors. (info Colo, Utah, NY)

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IOM Results (contd)

• Adverse events occurred in 2.9 3.7 of the
  hospitals studied. Of these adverse events 6.6
  13.6 resulted in deaths. Fifty percent of these
  adverse events were from preventable medical
  errors.
• The number of deaths due to medical errors
  exceeds the number of deaths resulting from
  motor-vehicle wrecks (43,458), breast cancer
  (42,297) and AIDS (16,516)

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IOM Results (contd)

• Total national costs (lost income, lost household
  production, disability, and health care costs) of
  preventable adverse events are 17 29 Billion.
  Health care costs are over 50
• Preventable injuries in hospitals affect 3 4
  of patients.

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IOM Results (contd)

• The majority of problems were system problems not
  the fault of individuals.
• A system is a set of interdependent elements
  interacting to achieve a common aim. The
  elements may be both human and non-human
  (equipment, technologies, etc.)
• Well-oiled machine
• Dominoes falling

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IOM RECOMMENDATIONS

• Establish a national focus on patient safety.
  This is done by
• Making patient safety EVERYONES responsibility
• Developing effective mechanisms for
  identifying/dealing with unsafe procedures and
  practitioners
• Simplifying processes and systems
• Standardizing processes (intertester/intratester
  reliability)
• Reporting errors immediately
• Ensuring no reprisals for reporting
• Developing a culture of openness and
  communication
• Implement feedback and learning from mistakes
• Anticipating the unexpected
• Respecting human limits

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IOM RECOMMENDATIONS

• Identify and learn from errors by establishing a
  nationwide mandatory and voluntary reporting
  system (encourage health care organizations to
  participate)
• In 2000, Pres. Clinton urged a state-based
  system of reporting medical errors to be phased
  in over time mandatory reporting of the med
  errors resulting in death or serious injury
  voluntary reporting of the other medical
  mistakes.

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IOM RECOMMENDATIONS (contd)

• Raise performance standards and expectations for
  improvements with multiple agencies,
  professionals and consumers.
• Implement safe practices at the delivery level
  and build a culture of patient safety.

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HISTORICAL SUMMARY

• Federal Level
• Presidential Action
• Advisory Commission
• Task Force
• Project (done by IOM)
• Results of Project (eye-opening)
• Several Senate Bills

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• State Level
• FS 456.013(7) passed
• Omnibus Health Care Bill was adopted (SB 1558,
  section 63)
• Hospitals were to evaluate systems for wrong site
  surgery, wrong patient, wrong procedure, and
  unnecessary procedures.
• FHA (Florida Hospital Association) organized an
  interdisciplinary Patient Safety Steering
  Committee.
• Developed practice models for all hospitals to
  incorporate into their patient safety programs
  on Safe Medication Practices, Safe Surgery
  Practice, and Falls Prevention.

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LAW (Reference Materials)

• FS 456.013(7)
• FS 486
• FAC 64B17 8.002

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Definitions
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SAFETY

• Freedom from accidental injury

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• Whether a person is sick or just trying to stay
  healthy, they should not have to worry about
  being harmed by the health system itself. IOM,
  1998

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MEDICAL ERROR

• The failure of a planned action to be completed
  as intended or the use of a wrong plan to achieve
  an aim.

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MEDICAL ERROR

• Planning use of a wrong plan to achieve desired
  aim
• Execution failure of a planned action to be
  completed as intended

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MEDICAL ERROR

1. Sentinel Events
2. Adverse Events
3. Close Calls
4. Intentional Unsafe Acts

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A. SENTINEL EVENT

• Unexpected events resulting in the death or
  serious physical or psychological injury of a
  patient

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EXAMPLES from MEDIA

• Betsy Lehman (a health reporter for the Boston
  Globe) died from an overdose during chemotherapy.
• Willie King had the wrong leg amputated.
• Ben Kolb (8 y.o.) died from a drug mix-up during
  minor surgery.
• Six year old boy died when a metal oxygen tank
  was pulled into the MRI.

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EXAMPLES from MEDIA

• Dr. Karl Shipman died from the orthopedic surgery
  for a broken wrist. Infection started and
  migrated to spinal column. Complaints of neck
  and back pain lead to prescription for PT. No
  vital signs or lab tests were taken.

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B. ADVERSE EVENTS

• Injury caused by medical management rather than
  underlying disease/condition of patient

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EXAMPLES from MEDIA

• Pat McEachern was paralyzed on the right side of
  her body as a result of a botched angiogram.
• Diane Artemis fell after a THR dislocating her
  hip. Fall went unreported. Six weeks later,
  x-rays revealed the problem. Two follow-up
  surgeries were needed. During Rehabilitation,
  hip was mishandled, and became less mobile. More
  surgery and radiation was needed.

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C. CLOSE CALLS

• (Sigh of relief, whew, and a silent thank
  you prayer!!!)
• What could have been a tragedy was averted

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D. INTENTIONAL UNSAFE ACTS

• Knowing something is hazardous and could
  compromise the safety of a patient, but is done
  anyway.

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NEGLIGENCE

• Failure to provide care for a patient within the
  established standard of care for the profession
  resulting in injury to the patient.

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MALPRACTICE

• Incorrect or negligent treatment of a patient by
  persons responsible for health care
• The patients medical record is used in 80 85
  of malpractice suits to establish treatment given
  and results of care.

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COMPARATIVE FAULT

• A legal concept permitting courts to distribute
  the damages to a patient between each negligent
  person involved in the legal action

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More Examples of MEDICAL ERRORS

• Wrong medication type
• Wrong medication dosage
• Wrong site surgery
• Misdiagnosis leading to incorrect therapies
• Misinterpretation of test/lab results
• Failure to act on abnormal results
• Equipment failure
• Infections
• Misinterpretation of medical orders
• Conditions of fatigue, stress, and pressure in
  the staff
• ETC, ETC, ETC

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BENCHMARKING

• Comparing your organizations performance with
  others similar to yours

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ERROR PRONE SITUATIONS

• Situations, procedures or circumstances during
  which medical errors are increasingly possible

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PERFORMANCE IMPROVEMENT

• Continuous effort on the part of the healthcare
  professional to find new and better ways of
  undertaking tasks and procedures.

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UNDERLYING CAUSE

• The system or process that allowed an undesirable
  event to occur.

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HIGH RISK POPULATIONS

• Elderly patients
• Patients with cognitive decline
• Patients with developmental or learning
  disabilities
• Psychiatric patients
• Infants and young children

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Medical Error Settings (JCAHO)

• General hospital
• Long Term Care Facility
• Psychiatric hospital
• Psych unit (gen. hosp)

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MEDICAL ERROR SITUATIONS (JCAHO)

• Op/post-op complications
• Medication errors
• ADR Adverse Drug Rxn.
• Wrong-site surgery
• Delay in treatment
• Falls
• Death/injury due to restraints
• Transfusion error

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REMEMBER!!!!

• A Medical Error is like a mosquito bite instead
  of a plane crashharm comes to one patient at a
  time making the accident less visible and
  possibly even looking insignificant. A plane
  crash results in many getting harmed at one time.
  It gets the immediate attention of everyone.

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ANALYSIS OF MEDICAL ERRORS

• Two methods
• The Root Cause Analysis (RCA)
• The Failure Mode and Effects Analysis (FMEA) The
  Healthcare Failure Mode and Effects Analysis
  (HFMEA)

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ROOT CAUSE ANALYSIS

• Looking for basic and contributing causal factors
• After the medical error has occurred.
• Retrospective or hindsight review
• Monday morning quarterbacking crime scene
  investigations (CSI)
• Hindsight bias
• Narrows the focus on the cause without
  considering the whole picture (environmental,
  emotional, political and system issues)

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FAILURE MODE AND EFFECTS ANALYSIS (FMEA HFMEA)

• Prospective analysis
• Systematic method of identifying and preventing
  product and process problems
• Before problem occurs
• Tries to anticipate the unexpected
• Puts the time, money and effort into the design
  of a process up front!

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PHYSICAL THERAPY

• Where are we the most vulnerable?
• The setting
• The types of patients
• The types of diagnoses
• Patient Management
• PT Department Management and Oversight

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Discussion
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LEADERSHIP FUNCTIONS

• Current accreditation standards from CAPTE
  address the safety issue being incorporated
  within PT/PTA curricula
• Clinical Performance Instrument (CPI) has a red
  flag designation on the PT/PTA behavior
  reflecting safety
• Guide to Physical Therapist Practice addresses
  safety throughout the document

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REMINDER

• When things get tough, and a medical error occurs
  (or the potential for a medical error is present)
  
• THINK OF LUCY
• And determine the cause system or personnel

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