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Four Actions The Hospitalist’s Role in Patient Safety. Mark B. Reid, MD Division of Hospital Medicine Denver Health Medical Center University of Colorado: GIM TMC February 17, 2009 Denver VA Hospital. To Err is Human: 1999 The flawed assumptions. Safety results from complexity

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four actions the hospitalist s role in patient safety

Four ActionsThe Hospitalist’s Role in Patient Safety

Mark B. Reid, MD

Division of Hospital Medicine

Denver Health Medical Center

University of Colorado: GIM TMC

February 17, 2009

Denver VA Hospital

to err is human 1999 the flawed assumptions

To Err is Human: 1999 The flawed assumptions

Safety results from complexity

Errors are caused by bad people

This problem will be easy to fix

what has worked

What has Worked?

Regulation: JCAHO

Reporting

Teamwork Training

IT

The End of the Beginning: Patient Safety Eight Years After the IOM Report on Medical Errors. Robert M. Wachter, MD, 12th Annual Management of the Hospitalized Patient, San Francisco, CA October 23, 2008

learning objectives

Learning Objectives

  • Know when to wash your hands
  • 2. Know who to call when an error occurs
  • 3. Name one intimidating behavior
  • 4. Name a common CPOE error
actions

ACTIONS

1. Do JCAHO2. Report errors3. Be available4. Beware computer errors

slide6

1. When rounding on your patients, you foam or wash your hands: A) neverB) before each patientC) after each patientD) whenever someone is watching E) before and after each patient

slide7

1. When rounding on your patients, you foam or wash your hands: A) neverB) before each patientC) after each patientD) whenever someone is watchingE) before and after each patient

what has worked8

What has Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT

hand hygiene

Hand Hygiene

Donskey and Eckstein 360 (3): e3, Figure 1 January 15, 2009

Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR-16)

practical script for hand hygiene hand washes are green arrows

P4

P5

Practical Script for Hand Hygiene(hand washes are green arrows)

Check labs

P1

P2

P3

Time

Answer phone

do jcaho

Action 1

Do JCAHO

National Patient Safety Goals: 2009

Correctly identify patients

Read back telephone orders

“Do not use” abbreviations

Critical values

Standardized “hand-offs”

Look-alike/sound-alike drugs

Wash your hands

Reconcile medications @ admit and D/C

Identify patients at risk for suicide

Mark site/time out

slide14

2. A patient is transferred to the floor from the MICU after a Tylenol overdose. What special step(s) should you take?A) speak directly to the psychiatry consultantB) confirm that patient has a mental health holdC) assign patient to a sitter roomD) check his bagE) all of the above

slide15

2. A patient is transferred to the floor from the MICU after a Tylenol overdose. What special step(s) should you take?A) speak directly to the psychiatry consultantB) confirm that patient has a mental health holdC) assign patient to a sitter roomD) check his bagE) all of the above

what has worked16

What has Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT

jcaho root cause analysis

JCAHO Root Cause Analysis

  • Hospitals obliged to report events to JCAHO
  • 42 reports covering “the worst” errors: PCA by proxy, delays in treatment, prevention of ventilator associated death
  • Example: 675 inpatient suicides reported as sentinel events
  • Sentinel Event Alert: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/
jcaho root cause analysis inpatient suicide

JCAHO Root Cause Analysis:Inpatient Suicide

  • Incomplete suicide risk assessment at intake
  • Failure to identify a contraband
  • Incomplete communication among caregivers.
  • Assignment of the patient to an inappropriate unit or location
report errors call risk management for never events

Action 2

Report ErrorsCall Risk Management for “Never Events”

Wrong side/site surgeryAir embolismPatient suicideDeath from medication errorDeath from hypoglycemia (<60)Stage 3 or 4 pressure ulcerDeath or severe disability from a fall

National Quality Forum Serious Reportable Events in Healthcare 2006 Update

slide23

3. A nurse tells you he noticed a patient was unsteady on her feet. The way you respond to this information could save another patient’s life.A) yesB) no

slide24

3. A nurse tells you he noticed a patient was unsteady on her feet. The way you respond to this information could save another patient’s life.A) yesB) no

what has worked25

What has Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT

behaviors that undermine a culture of safety

Behaviors that Undermine a Culture of Safety

Intimidating and disruptive behaviors can foster medical errors

Staff within institutions often perceive that powerful, revenue-generating physicians are “let off the hook”

A few commit many but many commit a few

http://www.jointcommission.org/SentinelEvents/SentinelEventsAlert/sea_40.htm

are you an intimidator

Are You an Intimidator?

  • Reluctance or refusal to answer questions, return phone calls or pages
  • Use of condescending language or voice intonation
  • Impatience with questions
  • Verbal outbursts or physical threats
teamwork

TEAMWORK

Sutker, James Baylor Medical Grand Rounds, 7/17/2007

slide31

The Correct Response to the Nurse

“Thanks for letting me know. That is very important information. You should always feel free to tell me when you notice anything.”

be available

Action 3

Be Available

Listen and respect staff opinionsBe approachable and availableDon’t be an intimidator

what has worked35

What has Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT

new errors in cpoe37

New Errors in CPOE

  • Wrong patient selected
  • Loss of chart personality
  • Warning desensitization
  • Order set ignorance

Sutker, James Baylor Medical Grand Rounds, 7/17/2007

beware computer errors

Action 4

Beware Computer Errors

1. Is this the right patient?2. Look up drug doses, especially for infrequently used medicines3. Be redundant—talk to a human being!

learning objectives39

Learning Objectives

Did you learn anything?

  • Know when to wash your hands
  • 2. Know who to call when an error occurs
  • 3. Name one intimidating behavior
  • 4. Name a common CPOE error
actions40

ACTIONS

1. Do JCAHO2. Report errors3. Be available4. Beware computer errors

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