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1. Patient Safety: How You Can Prevent Medical Errors Arpana R. Vidyarthi, MD
Associate Professor of Clinical Medicine
Director of Quality and Safety Programs, GME I am lucky to be the second person to welcome you to UCSF, and I have to say, I am very excited that you are hereI hope that most of you are also excited axious but mostly exicited about starting internshipwhich I guarentee will be one of the most challenging, exhillarating, and rewarding years of your life, but I know that there is one more groupnot represented here, the outgoing interns, who are thrilled at your presence. So on behaaf of themwelcome!I am lucky to be the second person to welcome you to UCSF, and I have to say, I am very excited that you are hereI hope that most of you are also excited axious but mostly exicited about starting internshipwhich I guarentee will be one of the most challenging, exhillarating, and rewarding years of your life, but I know that there is one more groupnot represented here, the outgoing interns, who are thrilled at your presence. So on behaaf of themwelcome!
2. Why Are You Here? my time in the developing world led me to
the scientific exchange that I experienced in the lab
UCSFs reputation You have spent decades of education getting to this pointand here you areabout to embark upon direct responsibility for patient carein our zeal to help people
I know you are sitting here worrieddo I know enough, how will I remember that diagnosis, or how to throw that tie. I will posit to you, that to achieve this goal, you need to not only think about those things, but consider another aspect of the care we deliverand
You have spent decades of education getting to this pointand here you areabout to embark upon direct responsibility for patient carein our zeal to help people
I know you are sitting here worrieddo I know enough, how will I remember that diagnosis, or how to throw that tie. I will posit to you, that to achieve this goal, you need to not only think about those things, but consider another aspect of the care we deliverand
3. The Institute of Medicine: 44,000 98,000 preventable adverse events yearly No patient safety talk would be complete without discussing the 1999 IOM report to err is human. Hopefully this isnt the first you are hearing about this reportbut over a decade ago, this report heralded the nature of what has been termed the epidemic of medical errors to healthcare providers, patients, legislators and everyone in between.
not only did it bring these data to a wide audience-made it accessible and palpable. 4th leading cause of death in the USadmission to a hospital
$17 billion are associated with preventable errorsNo patient safety talk would be complete without discussing the 1999 IOM report to err is human. Hopefully this isnt the first you are hearing about this reportbut over a decade ago, this report heralded the nature of what has been termed the epidemic of medical errors to healthcare providers, patients, legislators and everyone in between.
not only did it bring these data to a wide audience-made it accessible and palpable. 4th leading cause of death in the USadmission to a hospital
$17 billion are associated with preventable errors
4. Medical CareThen and Now marcus welbymarcus welby
5. First Do No Harm Safety of patients is our priority
.and we could be doing a better job! Maybe the most common thing you will do every day: write ordersMaybe the most common thing you will do every day: write orders
6. Individual Errors Are Common, And Expected Slips
Errors involving semi-automatic routines daily activities
exacerbated fatigue, competing tasks Mistakes
Errors in interpretation, misapplication of cognitive rules
more likely in new or unusual situations
7. The Swiss Cheese Model of Major Accidents & Errors
8. What Type of Human Glitches Cause Harm?
11. What is Our Goal? Freedom from accidental injury due to medical care, or medical errors
Patient Safety
What about safety todaywellinitial data shows that we are more aware, but not quite making an improving gradecomplexity of course. What about safety todaywellinitial data shows that we are more aware, but not quite making an improving gradecomplexity of course.
12. So What Can You Do About It? Use Communication Tools
Be Conscientious of Signouts
If you see something wrong, tell someone
Strategies to improve the safety of your patients, from your front line provider perspective, isnt really rocket science. I am going to go through 3 discrete strategies that you can use right away, next week when you are seeing patientsinpatients, outpatients, on the wards, and in the OR. 1,2,3Strategies to improve the safety of your patients, from your front line provider perspective, isnt really rocket science. I am going to go through 3 discrete strategies that you can use right away, next week when you are seeing patientsinpatients, outpatients, on the wards, and in the OR. 1,2,3
13. Communication Tools Read back for all verbal orders
Standardization for order sets
OR Time-Outs
SBAR For urgent or high-risk orders, make sure to speak to the nurse directlyFor urgent or high-risk orders, make sure to speak to the nurse directly
14. Case Presentation: Edith presents with SOB
15. Day 1
16. Day 2
17. The first 48 hours of Ediths stay. Resident: Do you remember us Edith, we are the doctors taking care of you?
Edith: Uh.no?
Resident 5 to intern: She seems altered. Lets get a stat head CT. How many of you have ever played the game operator? If you have, I dont even have to make an argument about the potential for errors with handoffs.How many of you have ever played the game operator? If you have, I dont even have to make an argument about the potential for errors with handoffs.
18. Why So Many Handoffs Today? ACGME duty hour limitations
80 hours per week
30 hours continuous
24 hours off per month
Practicing physicians
Group practices: cross-coverage
Hospitalists
Days of residencynew lookin an effort to primarily reduce the errors associated with resident fatigue, ACGME-the body that accredits residencies, reduced the number of hours that residents across disciplines could work.
IM residency 1 month rotations, internship, signout more than the number of patients that they will admit in their entire internship, more than the largest order that they will write (bolus of saline) more than the freuqency that they will eat in a month300/month.
Think in patient and outpatinet
Turnover: LOS, outpatientDays of residencynew lookin an effort to primarily reduce the errors associated with resident fatigue, ACGME-the body that accredits residencies, reduced the number of hours that residents across disciplines could work.
IM residency 1 month rotations, internship, signout more than the number of patients that they will admit in their entire internship, more than the largest order that they will write (bolus of saline) more than the freuqency that they will eat in a month300/month.
Think in patient and outpatinet
Turnover: LOS, outpatient
19. Housestaff Experiences handoffs are dangerous
A common suboptimal care practice
59% report patient harm
Increased errors from discontinuity
Clinical
Delayed test ordering
Increased in-hospital complications
Increased medication errors
Presumed increase in length of stay
Perceptions Impacts Numerous articles have been published in a vareity of disciplines addressing resident perceptions regarding handoffs. In general, these points summarize some of the conclutionsNumerous articles have been published in a vareity of disciplines addressing resident perceptions regarding handoffs. In general, these points summarize some of the conclutions
20. Discontinuity and Patient Harm Most significant risk for an adverse event:
cross-covering MD
21. Handoff Best Practices University Health Consortium
Position Papers
IM, ER, Surgery, Hospital Medicine
Society of Hospital Medicine
Joint Commission
24. Communication Channels
25. Think About What You Would Want To Know Who
What
Administrative Data
Problem list
To Do List
Nuance
Where
26. What Can You Do To Diminish Harm at Signouts? Take it seriouslywe do
Use standardized toolsthey work
Verbally sign outit matters
Role modelremember yesterday
27. Individual Errors Are Common, And Expected Slips
Errors involving semi-automatic routines daily activities
exacerbated fatigue, competing tasks Mistakes
Errors in interpretation, misapplication of cognitive rules
more likely in new or unusual situations
Remember this? well, I dont know about you, but these are the sorts of things that I do everydayand given the fact that the swiss cheese has holes, every once in a while, something bad will happen, or might happen to a patient just because I am human. It isnt just about humans, but also the systems that we have in placethey just dont workin fact our own research shows that more than 1/3 of you have experienced a medical error. Remember this? well, I dont know about you, but these are the sorts of things that I do everydayand given the fact that the swiss cheese has holes, every once in a while, something bad will happen, or might happen to a patient just because I am human. It isnt just about humans, but also the systems that we have in placethey just dont workin fact our own research shows that more than 1/3 of you have experienced a medical error.
28. So What Do You Do When? Report problems
Incident reports/near miss reports
Let us know: arpana@medicine.ucsf.edu,
Tell your chief residents!
Dont fear the RCA
Chiefsmeet with GME and hospital leadership monthly
Near miss reporting (anesthesia)
Hospital IR reports are followed up by every department
Resident & Fellows Committee, CPOEChiefsmeet with GME and hospital leadership monthly
Near miss reporting (anesthesia)
Hospital IR reports are followed up by every department
Resident & Fellows Committee, CPOE
29. Case Review: To Fix the System Medical center level
Multi-disciplinary
Clinical Events Oversight Committee
Systematic review of the events including participants with actions Department/division based
Single discipline
M and M/Peer Review/Case Review
Discussion and review by peers Root Cause Analysis Case Review-Peer Review Apparent cause analysisApparent cause analysis
30. Engage the Process You are the one with the knowledge: events
Clinical
Operational
Systems
You are the one with knowledge: solutions
Experience
Feasibility
Culturally applicable
31. Safety and Quality Today Freedom from accidental injury due to medical care, or medical errors
The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Safety
Quality What about safety todaywellinitial data shows that we are more aware, but not quite making an improving gradecomplexity of course. What about safety todaywellinitial data shows that we are more aware, but not quite making an improving gradecomplexity of course.
32. And on the Quality Front Table 3. Adherence to Quality Indicators, Overall and According to Type of Care and Function.
McGlynn and colleagues from rand corporation 20,000 geographically diverse patients almost 500 quality indicators
Tranisitionman made epidemicwe dont have to wait for a sceintific Table 3. Adherence to Quality Indicators, Overall and According to Type of Care and Function.
McGlynn and colleagues from rand corporation 20,000 geographically diverse patients almost 500 quality indicators
Tranisitionman made epidemicwe dont have to wait for a sceintific
33. UCSF Programs to Improve Quality Curriculum in your department
Opportunities for Q/S projects
Resident engagement on committees
Patient Care Fund
Resident Quality and Safety Committee
34. UCSFMC/GME Incentive Program
35. Program Specific Incentives Anesthesia
Increase rate of prophylactic antibiotics
Dermatology
Decrease clinic wait times
EM
Increase PCP communication
Peds
Asthma action plans
Neuro
Improve swallow exams on stroke pts
Medicine
Increase PCP communication
Neurosurgery
Ontime start in the OR
ObGyn
Improve DM orders
Radiology
Critical results reported
36. Safety and Quality are About Systems Problem in healthcare = assumption of individual responsibility/blame for errors
Must recognize that medicine is a team effort, involving MDs, nurses, pharmacists, etcProblem in healthcare = assumption of individual responsibility/blame for errors
Must recognize that medicine is a team effort, involving MDs, nurses, pharmacists, etc
37. Safety and Quality are About Systems Problem in healthcare = assumption of individual responsibility/blame for errors
Must recognize that medicine is a team effort, involving MDs, nurses, pharmacists, etcProblem in healthcare = assumption of individual responsibility/blame for errors
Must recognize that medicine is a team effort, involving MDs, nurses, pharmacists, etc
38. You Can Change The Script Prioritize safety in your everyday work
Use communication tools
Signout patients with care
Report problems you see
Ask for help!
Think about the quality of care provided
Engage the systems Think back to just a few weeks agoone of the foundational tenents of the oath that many of you took is to first do no harm. And think to years agoyour goalsqualtiy and safety is a main way that we can Think back to just a few weeks agoone of the foundational tenents of the oath that many of you took is to first do no harm. And think to years agoyour goalsqualtiy and safety is a main way that we can
39. THANKS