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Lessons Learned on Patient Safety. FCC of MHRI. The Present Culture. 12 minutes for every encounter, 18 seconds elapse before 1 st interruption and 75% leave with unanswered questions. Medication safety: 25% of patients in a year had Adverse Drug Reaction 11% preventable

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Lessons Learned on Patient Safety

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Lessons learned on patient safety

Lessons Learned on Patient Safety


The present culture

The Present Culture

  • 12 minutes for every encounter, 18 seconds elapse before 1st interruption and 75% leave with unanswered questions.

  • Medication safety: 25% of patients in a year had Adverse Drug Reaction

    • 11% preventable

    • 3% were potential to harm and 95% of these would have been prevented

Lessons learned on patient safety

Levels of maturity with respect to a safety culture

E. Risk management is an integral part of everything that we do

D. We are always on the alert for risks that might emerge

C. We have systems in place to manage all identified risks

B. We do something when we have an incident

A. Why waste our time on safety?






Safety minefields

Safety Minefields

  • Transitions of Care

    • 20% after discharge had a significant result: Med errors lead the pack

    • Only 25% mentioned pending tests F/U

  • Missed or Delayed Diagnoses

  • Cognitive Errors: Reliance on Memory

  • Test tracking, Ordering of tests and F/U

  • Referrals: timeliness and clarity

Medication pitfalls

Medication Pitfalls

  • Survey says: 200,000 Rxs written only 72% were filled

  • Adherence and Medication reconciliation

    • Ask-Educate-Ask

Take home points

Take home Points

  • Transitions of Care

    • Template for first visit after discharge

    • Bullet points on Discharge summary of most important topics, pending tests, labs and procedures done

    • Must be available at first visit: only 12% are available

    • Medication Reconcilliation at every step

Test tracking

Test Tracking

  • No News is not good news!

  • How does the patient prefer to be contacted about results: phone, e-mail, snail mail

  • If you do not hear from the office in X amount of time after the study should take the initiative to contact the office.

  • Order entry will help not to lose tests

  • Tickler systems essential for tests and referrals

  • Standardize process and procedures

Culture of safety

Culture of Safety

  • Walk Rounds

    • Senior level engaging and NON-punitive

  • Safety Huddles: Huddles to Shape the Day and regular huddles

  • Debriefings at the End of the Day and after any event.

  • Event Reports: Primary Care M & M

Culture of safety1

Culture of Safety

  • Need safe and supportive Accountability

  • Need Resources

  • Clinical Decision Support at P.O.C.: Algorithms

  • Big hitters: Cancer prevention,tests and follow up

  • Communication in the office, at the hospital, with the specialists and the administration

  • Consistency, Teamwork, Safe environment



  • Trigger Tools

  • Ambulatory Safety Survey: ARQHC

  • MGMA: Patient Safety Score

  • Donabedian: Structure + Process = Outcome

  • MaPSaF safety culture assessment

Trigger tool

Trigger Tool

Primary care trigger tool

Primary Care Trigger Tool

London protocol

London Protocol

Tool benefits

Tool Benefits

Individual benefits

Individual Benefits

Framework document

Framework Document

Next steps

Next steps

  • Pre Huddles and post Huddles

  • Trigger Tool Use

  • Better tracking of tests, reports, reminders

  • Transparent Walk Rounds

  • Standardization for test notification,

  • Standardization for using EMR medication reconcilliation

  • Keep up the transition of care excellence

  • Decision support tools in the EMR

  • First visit post hospitalization template

  • Patient surveys and practice survey tools

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