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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

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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

Safety results from complexity

Errors are caused by bad people

This problem will be easy to fix


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

  • 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

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


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


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 Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT


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)


# Washes ≥ [# Patients] + 1


P4

P5

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

Check labs

P1

P2

P3

Time

Answer phone


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


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


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 Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT


The Promise of Error Reporting:Safety in Air Travel


Joint Commission:National Patient Safety Goals


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

  • 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


The case of the pills in the bag


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


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


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 Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT


Crashing Flight Simulators


JCAHO


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?

  • 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

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


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.”


Action 3

Be Available

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


4. Do computers increase safety?A) yesB) no


4. Do computers increase safety?A) yesB) no


What has Worked?

Regulation: JCAHO = rules

Reporting

Teamwork Training

IT


New Errors in CPOE


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


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 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


ACTIONS

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


Questions?


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