Patient Safety in Ambulatory Care ECMH Grand Rounds February 22, 2013

1. Patient Safety in Ambulatory Care ECMH Grand RoundsFebruary 22, 2013 Donna Woods, EdM, PhD & Dan Evans, MD, MS

2. ECMH Updates • No Grand Rounds next month • Student surveys coming this weekend… • Next month each clinic will be receiving a QI scorecard & will be asked to design at least 1 PDSA • Clinic attendance… • Follow ECMH on twitter https://twitter.com/devans_at_NUmed • Or try our new webpage: • http://www.feinberg.northwestern.edu/education/curriculum/learning-strategies/education-centered-medical-home/index.html

3. Overview • Definitions • Epidemiology of Risk in Ambulatory Care • Specific Areas of Focus • ECMH Patient Cases • ECMH Team Discussions of Approaches • Report Out and Discussion

4. Definitions WHO Guidelines for Adverse Event Reporting and Learning Systems Patient safety: Freedom from accidental injuries. Error: The failure of a planned action to be completed as intended (i.e. error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning) (3). Errors may be errors of commission or omission, and usually reflect deficiencies in the systems of care. Adverse event: An injury related to medical management, in contrast to complications of disease (4). Medical management includes all aspects of care, including diagnosis and treatment, failure to diagnose or treat, and the systems and equipment used to deliver care. Adverse events may be preventable or non-preventable. Preventable adverse event: An adverse event caused by an error or other type of systems or equipment failure (5). “Near-miss” or “close call”: Serious error or mishap that has the potential to cause an adverse event but fails to do so because of chance or because it is intercepted. Hazard: Any threat to safety, e.g. unsafe practices, conduct, equipment, labels, names.

5. Epidemiology1999 Institute of Medicine Report To Err is Human: Building a Safer Health System • 44,000-96,000 preventable adverse events occur each year in the United States • 5th leading cause of death • Estimated costs of 38 – 50 million for adverse events (4% of healthcare costs).

6. New Epidemiology 2010 • 180,000 preventable adverse events occur each year in Medicare patients in the United States • 13% of Medicare beneficiaries experienced at least one adverse event resulting in serious patient harm • 5th3rdleading cause of death • Estimated costs of 38 – 50 19.5 Billion for adverse events Department of Health and Human Services Office of the Inspector General: Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, November 2010, OEI-06-09-00090. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf. Accessed January 5, 2012.

7. 47% of People Concerned about Errors in Hospitals (Kaiser/AHRQ, 2000)

8. Student Presentations ECMH Cases What safety issues have you seen in your clinics recently?

9. Studying Ambulatory Adverse Events Ambulatory events leading to hospital admission Events detected in electronic system Malpractice claims Collection of provider reports

10. Adverse Events in Ambulatory Care Settings • Based on the Conservative IOM Data • Ambulatory events leading to hospital admission • ~171,000 discharges annually in the US related to ambulatory care adverse events • ~76,000 discharges annually related to ambulatory care preventable adverse events Woods et. al., QSHC, 2007

11. Ambulatory Care Preventable Adverse Event Types Event Type Preventable Adverse Events • Preventable Adverse Events • Diagnostic • Surgical • Harm • Surgical (X = 4.0) • Diagnostic (X = 3.4) • No significant difference among the others

12. Ambulatory CarePreventable Adverse Events Ambulatory Care Setting Type Preventable Adverse Events • Most common setting of Preventable Adverse Events • Physician’s Office • ED • Home • Mean Harm • Highest in Ambulatory Surgery • Diagnostic

13. Ambulatory Care Preventable Adverse Events Ambulatory Care Provider Type Preventable Adverse Events • Preventable Adverse Events • Primary Care • Emergency Medicine, Medical, and Surgical Specialties • Harm • Primary Care (X = 4.0) • Emergency Medicine, Surgical and Medical Specialties (X = 2.5 – 3.0)

14. Breakdown Points in the Diagnostic Process in Ambulatory Care Gandhi, T. K. et. al. Ann Intern Med 2006;145:488-496

15. Communication

16. 243 physicians reported 639 reports with 1010 errors Frequency of Lab Testing Errors Dovey SM, Meyers DS, Phillips RL Jr., et. al. A preliminary taxonomy of medical errors in family practice. QualSaf Health Care. 2002 Sep;11(3):233-8

17. Outpatient Medication Safety • In a seminal study of 24 outpatient practices • 1879 prescriptions from 1202 patients • Outpatient medication errors in 27 of 100 patients • 62 (3% of all prescriptions) had potential for patient injury (potential ADEs); • 1 was potentially life-threatening (2%) and 15 were serious (24%). • Errors in frequency (n=77, 54%)and dose (n=26, 18%) were common. • Advanced checks (including dose and frequency checking) could have prevented 95% of potential ADEs. Ghandi TK, Weingart S, Seger AC, et. al. Outpatient Prescribing Errors and the Impact of Computerized Prescribing. Journal of General Internal Medicine, 2005; Volume 20, Issue 9, Pages 837-841

18. The rate of outpatient ADEs may be ~4 X as high as that reported in hospital studies and More than one third of these events are preventable Number of medications significantly associated with adverse events Adverse Drug Events in Ambulatory Care Gandhi et. al. 2003

19. Ambulatory Care Medication Adverse Events • Forty (70%) of the preventable ADEs were related to parent drug administration. • Improved communication between health care providers and parents and improved communication between pharmacists and parents, whether in the office or in the pharmacy, were judged to be the prevention strategies with greatest potential. Kaushal, et. al., 2007

21. ASIPS Study: Frequency of Errors 475 physicians submitted 608 reports Fernald DH, Pace WD, Harris DM, West DR, Main DS, Westfall JM. Event reporting to a primary care patient safety reporting system: A report from the ASIPS Collaborative. Ann Fam Med. 2004 Jul-Aug;2(4):327-32

22. AAFP National Research Network Error Reports 42 physicians made 344 reports Dovey SM, Meyers DS, Phillips RL Jr., et. al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002 Sep;11(3):233-8

23. Australia Error Reports 324 GPs reported 805 incidents in 1993-1995 Bhasale AL, Miller GC, Reid SE, Britt HC. Analyzing Potential Harm in Australian General Practice: An Incident-Monitoring Study. Med J of Australia 1998;169:73-76.

24. Ambulatory Adverse Events • Diagnostic errors: • Most frequent and most harmful • Range from trivial failures (overlooking a minor lab abnormality) to more serious errors (switching of specimens between two patients) • Seven stages in the diagnostic process, with potential for error at each stage: • Access and presentation; history taking; physical examination; testing; assessment; referral; and follow-up • Communication errors: • Hospital discharge communication • Research on follow-up of tests pending at discharge • Discontinuity of care at care transitions • Communication of test results • Communication and non-adherence • Between-team communication • Medication safety: • Drugs widely used, with narrow therapeutic ranges and high toxicities associated with ADEs and/or medication errors • Elderly, taking many medications, comorbidities • Medication reconciliation

25. How do we achieve safety in health care? • Safe Culture • Safe Systems • Safe People • Error (event) reporting, surveillance, and other data gathering methods inform improvement • Improvement Methods

26. High Reliability Organizational Principles of Safe Culture • Preoccupation with failure • Reluctance to simplify • Sensitivity to operations • Commitment to resilience • Deference to expertise Continuous Learning and Improvement

27. Changing the Paradigm “Everything’s Fine” OutIn All is fine Endless opportunities for improvement Errors are rare Errors everywhere Tell as little as you can Tell whatever you can Keep Board out Actively involve Leadership MDs don’t participate Docs actively involved Our error rate is average No threshold for errors

28. CUS C Concerned U Uncomfortable S Safety Issue

29. Student Presentations ECMH Cases: What safety issues have you seen in your clinics recently?

30. ECMH Teams Meet to discuss challenges in your ECMH home • How common are medical errors? • What is the proper student response when confronted with a medical error about to happen? • What is the proper student response when confronted with a medical error that has already occurred? • Should the student report it? • How ? • When? • To whom? • Is there a support number or contact for students to call?

31. Hypothetical scenarios: You’re an M4 student and you are excited that Epic allows you to write medication orders – you write a new script for glyburide for your 85 yo diabetic and you realize the next week that you had accidently doubled the dose and your attending signed your script without catching the error… Reportable? How? When? To whom? What if you just asked your for a letter of rec?

32. Hypothetical scenario: You’re an M3 student . You are following your patient’s progress remotely. Last week your patient needed a script for his tuberculosis meds called into the pharmacy. You had asked your attending to e-Rx the meds, and you reminded him again at the end of clinic huddle. One week later there’s no script… Reportable? How? When? To whom? Do you feel comfortable calling your preceptor?

33. Hypothetical scenario: You’re an M2 student . You go visit your 84 yo patient in the hospital who was admitted 3 days ago for failure to thrive. You find she has a foley catheter (not indicated), her med list was changed (ambien & benedryl were added) and the team is ordering a CT scan to look for PE (but her GFR is 30). You have some safety concerns… Reportable? How? When? To whom? Are you comfortable voicing concerns to hospitalist?

34. Discussion & Wrap-up