©2012 American Academy of Neurology
Patient Safety 101 Patient Safety 101 for Neurologistsfor Neurologists
©2012 American Academy of Neurology
Overview The history of patient safety Situations that lead to medical errors Case studies How do we avoid medical errors
©2012 American Academy of Neurology
Patient Safety: The History
Hippocrates – “Primum Non Nocere”Hippocrates – “Primum Non Nocere”• BeneficenceBeneficence• Non-malfeasanceNon-malfeasance
Florence Nightingale Florence Nightingale • ““It may seem a strange principle to It may seem a strange principle to
enunciate as the very first requirement in enunciate as the very first requirement in a Hospital that it should do the sick no a Hospital that it should do the sick no harm.”harm.”
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The History of Patient Safety Post-World War II
• Modern advances in the ability of medicine to help were accompanied by a corresponding increase in the ability to do harm
Studies of the impact of medical errors began to appear in late 1980s to early 1990s
Harvard Medical Practice StudyReviewed >30,000 charts from randomly selected patients in acute
and non-acute hospitals in New Yorko 3.6% of hospitalized patients experienced
adverse events resulting in harmo 70% of these events resulted in disability lasting
less than 6 months, 13.6% resulted in death, 2.7% permanent disability
©2012 American Academy of Neurology
The History of Patient Safety
Quality of Australian Health Care Study in 1995
• Placed greater emphasis on quality of care than negligence, i.e., could the adverse event be prevented?
• Reviewed >14,000 charts from 28 hospitals 16.6% of hospitalized patients experienced adverse events
o 77.1% of those had disability lasting less 12 monthso 13.7% with permanent disabilityo 4.9% ended in death
51% of the adverse events were considered preventable
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The History of Patient Safety
In early 1995 an epidemic of errors erupted
• Michigan --a surgeon performing a mastectomy on a 69-year-old patient removed the wrong breast
• New York--a woman died when a doctor mistook her dialysis catheter for a feeding tube and ordered food to be pumped into her abdomen
• Tampa --a 51-year-old diabetic had the wrong foot amputated and a 73-year-old retired electrician died when a therapist mistakenly disconnected his ventilator
©2012 American Academy of Neurology
The History of Patient Safety
Institute of Medicine Report “To Err is Human”• Landmark paper published in 1999
Estimated incidence of patients who die in hospital due to preventable medical error
Was the springboard for emphasis on patient safety, quality improvement initiatives, and ultimately pay for performance
©2012 American Academy of Neurology
What is Medical Error?
Definition according to IOM• Failure of a planned action to be completed as intended or the
use of a wrong plan to achieve an aim
• Examples: adverse drug eventssurgical injuries and wrong-site surgeryrestraint-related injuries or deathfallspressure ulcers
©2012 American Academy of Neurology
The History of Patient Safety: IOM report “To Err is Human”
Medical error is the 8th leading cause of death in the US.
Medical errors cause 98,000 deaths per year.
More people die from medical error than from breast cancer, HIV, or MVAs.
©2012 American Academy of Neurology
Types of Error Diagnostic
• Failure to order appropriate test• Delay in diagnosis• Failure to act on results or monitoring
Treatment• Error in the performance of an operation, procedure, or test• Error in administering the treatment• Error in the dose or method of using a drug
Preventative• Failure to provide appropriate monitoring or follow-up• Failure to provide prophylactic treatment
Other• Failure of communication• Equipment failure• Other system failure
USA TODAYThursday, June 28, 2001
USA TODAYThursday, June 28, 2001
Hospital mistakes must be disclosed
Accreditation at risk if patients aren’t told
By Robert DavisHospitals must now tell patients and their families when they have been hurt by a medical error, according to nationwide standards that take effect Sunday.
The standards by the nation’s leading health care accrediting agency are the first to hold hospitals accountable for a higher level of patient safety. …
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How Unsafe is Healthcare??
Deaths per 100 million hours
Being pregnant 1Traveling by train 5Working at home 8Working in agriculture 10Driving 50Working in construction 67Being hospitalized 2000
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Cost of Medical Error Estimated direct cost of medical error in US $17 billion
Preventable adverse events to Medicare patients estimated to cost in excess of $880 million annually
A study from 2008 revealed overall cost of medical error in the US to be >$19.5 billion• Total cost per error approx. $13,000• >2500 avoidable deaths• >10 million days of lost productivity at work, costing $1.1 billion in
short-term disability claims
©2012 American Academy of Neurology
Cost of Most Common Medical Errors
Event Number of injuries 2008
% considered due to error
Medical cost per event
Total cost per event
Pressure ulcers 394,699 >90 $8730 $10,288
Post-operative infections
265,995 >90 $13,312 $14,458
Mechanical complication of device, implant or graft
268,353 10-35 $17,709 $18,771
Hemorrhage complicating procedure
156,433 35-65 $8,665 $12,272
©2012 American Academy of Neurology
Why is Healthcare Prone to Error?
Multiple and varied interactions with technology
Many individuals involved in care Multiple hand-offs High acuity of illness Distracting work environment Rapid, time-pressured decisions High volume, unpredictable patient flow Multiple step processes
©2012 American Academy of Neurology
Why is Patient Safety Important to Me?
It can save lives It can make YOU a better physician It is part of every hospital plan – no matter where
you work Focused programs are required by the Joint
Commission It is a required part of resident education
curriculum by the ACGME and RRC
©2012 American Academy of Neurology
How Does This Affect Neurology?
Many patient groups at risk• Stroke patients with many comorbid illnesses
Potential for drug interactionsHigh risk for falls
• Seizure patients with poor compliance or complex regimens
• Parkinson’s patients and dementia patientsSignificant cognitive impairment may result in
medication errorPhysical disabilities may increase risk of falls and
injury
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Of the 300 neurologic lawsuits requiring a pay out in 2004, most common diagnoses:
Disc disorder Stroke Headaches/migraine Seizure Cancer Meningitis Paralysis Aneurysm
©2012 American Academy of Neurology
National Academy of Science’s Institute of Medicine (IOM)
In 2001, the IOM laid out six dimensions of quality for health care.
According to the IOM, health care should be• Safe • Effective• Patient-centered• Timely• Efficient • Equitable
©2012 American Academy of Neurology
Patient Safety and Quality Improvement Act of 2005
Signed into Law 7/29/05 Nationwide Goals
• “To encourage the voluntary reporting of medical errors”• Report to “Certified Patient Safety Organizations”
Many providers fear repercussions • Act provides federal legal privilege and confidentiality protection
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Location of Patient Safety Organizations by State
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Joint Commission Goals
Improve the accuracy of patient identification• “NEVER” events
Improve the effectiveness of communication among caregivers
Improve the safety of using medications
Reduce the likelihood of patient harm associated with the use of anticoagulation therapy
Reduce the risk of health care-associated infections
©2012 American Academy of Neurology
Joint Commission Goals
Accurately and completely reconcile medications across the continuum of care
Reduce the risk of patient harm resulting from falls
Encourage patients’ active involvement in their own care as a patient safety strategy
Recognize and respond to changes in a patient’s condition
Crossing the Quality Chasm– IOM report• IOM was supposed to be balanced
“…to strike a balance between regulatory and market-based initiatives, and between the roles of professionals and organizations”
• But it was compliance-heavy“…to create sufficient pressure to make errors so costly in terms of ability
to conduct business in the marketplace, market share and reputation that the organization must take action”
JCAHOJCAHOEstablish disease -specific
care performance indicators and mandatory reporting for accreditation
High quality SAFE patient
careGovernmentGovernment
Monitor providerorganizations through
mandatory and voluntaryreporting EmployersEmployers
Provide incentivesto providers that use
tools to increase safety.
ProvidersProvidersImplement tools that supportclinical decision making and
prepare for new reporting requirements.
PayorsPayorsProvide incentives to
providers that use tools to increase safety and can
demonstrate performance
©2012 American Academy of Neurology
“Traditional” Patient Safety
Honored traditional teaching Blame… Shame… Denial… Errors are caused by…
Time-honored solutions to error? Anger… Shoot the messenger… Work harder…Try harder… Blame the system…
©2012 American Academy of Neurology
“Culture”
The system of shared beliefs, values, customs, behaviors, and artifacts that the members of that society use to cope with their world and one another,
AND
… that are transmitted from generation to generation through learning.
©2012 American Academy of Neurology
“Culture of Safety”
• Acknowledges high-risk, error-prone nature of modern health care
• Shared acceptance of responsibility for risk reduction
• Encourages open communication about safety concerns in non-punitive environment
©2012 American Academy of Neurology
“Culture of Safety”
• Facilitates reporting of errors and safety concerns
• Learns from errors and redesigns safer systems
• Ensures that organizational processes, goals, and rewards are aligned with improving patient safety
MOST COMMON THINGS THAT CAN RESULT IN HARM TO PATIENTS
#1 MEDICATION ERRORS
©2012 American Academy of Neurology
1. Medication Errors
Occur frequently in hospitals• Approximately 2% of admissions experienced preventable Adverse
Drug Event (ADE)• Estimated increased cost $5000 per patient• ADEs cost about $5.6 million per hospital annually
Average cost per ADE in tertiary hospital $3244 with increased length of stay (LOS) of 2.2 days
Average cost per ADE in community hospital $3420 and increased LOS of 3.1 days
©2012 American Academy of Neurology
Medication Errors Most common medications associated with harm
• Anticoagulants• Antidepressants• Antipsychotic medications• Cardiovascular drugs• Analgesics
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Predictors of ADEs Cannot solely be predicted based on patient factors or
drug types
Some associated risks:• Older age• Polypharmacy• Severity of illness
©2012 American Academy of Neurology
Medication Errors:
What can you do to reduce error or potential harm?
Check your orders for accuracy of dosingCheck medication interactions
Ask specifically about herbals and OTC productsCheck medication side effects and ask the patient about these on
subsequent visitsCheck to see that the patient is receiving the medication as
prescribedEncourage patients to bring in written listsUse EHR
#2 POOR COMMUNICATION
©2012 American Academy of Neurology
2. Poor Communication
In an average 4-day hospital stay, a single patient may encounter up to 50 different hospital employees
More than 1/5 of patients reported hospital system problems• Staff providing conflicting information• Not clear who the physician responsible for their care is
©2012 American Academy of Neurology
Poor Communication
With ineffective communication, great potential for harm• Lack of critical information• Misinterpretation of information• Overlooked change in status• Unclear orders over the phone
Communication errors identified as the root cause of sentinel (“Never”) events reported to the Joint Commission from 1995 to 2004
©2012 American Academy of Neurology
Barriers to Effective Communication
Hierarchical differences Inter-professional and intra-professional rivalries The health literacy of the patient Differences in language and jargon Cultural differences Generational differences
©2012 American Academy of Neurology
Barriers to Effective Communication Despite your best efforts to communicate and your
belief that your have communicated effectively, more patients than you may realize don’t understand what you think they understand.
Rarely will patients reveal limitations in their understanding because they are embarrassed to do so.
©2012 American Academy of Neurology
Barriers to Effective Communication
Health Literacy - Factors affecting patients’ ability to understand
• Ability to read • Ability to understand English• Ability to understand medical “lingo”• Cultural / ethnic views of cause and treatment of
disease• Complexities of health care system
©2012 American Academy of Neurology
What can we do to improve communication within the health care team?Ensure that the information is conveyed between staff
members at shift changes.Written sign out including diagnosis, clinical status of patient,
pending results, key test results, allergies, CODE status, and “what to do if…”
If possible, bring the nurse into the room to demonstrate the current findings and specific things that you want to be notified about.
Document the teaching and follow-up. ASSUME NOTHING!
©2012 American Academy of Neurology
What can we do to promote effective communication with our patients? Speak in plain everyday terms– avoid medical jargon Use teach-back methods When possible utilize pictures or diagrams Provide written information or handouts Make every attempt to use a medical translator for
those patients who are non-English speakers
©2012 American Academy of Neurology
3. Infection Resulting from Lines and Tubes
Don’t use a Foley catheter unless it is absolutely necessary.
Lines should be dated and checked daily Lines should be removed as early as possible,
and if there is ANY sign of infection
As of 2009, CMS and some insurance companies will not pay for infections that develop once a patient is in the hospital
©2012 American Academy of Neurology
4. The Patient is Not Sufficiently Monitored
Patients may need frequent vitals monitoring, telemetry, serial lab testing depending on their condition
No one will fault you for being “overly cautious”
©2012 American Academy of Neurology
5. Handwriting Errors in misinterpretation of written orders
account for a large percentage of inpatient mistakes.• Avoid use of trailing zeros
Use 5mg not 5.0mg• Use leading zeros
0.5mg
Standardized order sets are used to help decrease orders of OMISSION.• However may increase orders of COMMISSION due to
duplication of tests or inappropriate medications/tests
Use of electronic health record systems can reduce errors caused by handwriting
©2012 American Academy of Neurology
6. The Diagnosis is Not Clear A wrong diagnosis is made because of failure to order
the appropriate test
Always evaluate for life-threatening processes that require immediate attention (stroke, myocardial ischemia, pulmonary embolism, intracranial hemorrhage) as appropriate
Review all test results in a timely fashion to ensure that patients are treated appropriately
Who will notify the patient about their test results? How will they be notified?
©2012 American Academy of Neurology
7. New Information is Ignored
Lab results in clinic resulted but not reviewed or patient not notified of result
Additional history from patient or family
A patient admitted for one thing may develop a new problem while hospitalized • (e.g., patient with a stroke develops an MI)
©2012 American Academy of Neurology
8. The Patient Who Needs Frequent Blood Monitoring: Diabetes and Anticoagulation
Insulin dosing errors in patients who are not eating Glucose fluctuations in patients who have
infections/stress of illness
Increased risk for bleed in anticoagulated patients Interactions with other medications
• Ex. Many drugs interact with warfarin and may cause INR to increase or decrease
• Ex. Antibiotics may interact with and alter levels of anti-epileptic drugs
AND LAST BUT NOT LEAST. . .
©2012 American Academy of Neurology
THE PHYSICIAN WHO ASSUMES THAT ERRORS DO NOT OCCUR! If we carefully review our work, we are less likely to
make errors
We should avoid making the same mistakes over again- system and practice change
“If you don’t have time to do it right the first time, how are you going to have the time to go back and fix it later?”
CASE STUDIES
©2012 American Academy of Neurology
Case 1 Patient admitted to stroke service by night float
resident (or hospitalist). EKG ordered as part of standard order set.
EKG result not reviewed by the night float (hospitalist); signed out by phone to the day resident (or next shift) who has 4 new admits and forgets to check about the EKG.
Medicine consulted for HTN management 2 days later and notices EKG with evidence of MI on admit.
©2012 American Academy of Neurology
Case 1: Key Learning Points
Review all test results and history at time of admission and also transitions of care
Adequate handoffs and sign-out are critical, optimally are written
Communication between providers is best done face to face
©2012 American Academy of Neurology
Case 2
Neurology consulted for patient with delirium in ER
The patient has history of seizures. Lab tests reveal a phenytoin level of 65, and patient is ataxic on exam
Resident does not communicate situation to nursing staff• Patient is placed in room away from nursing station without
bedrails up, and no falls precautions noted.
Patient falls out of bed attempting to go to bathroom and suffers subarachnoid hemorrhage and subdural hematoma.
©2012 American Academy of Neurology
Case 2: Key Learning Points Recognition of adverse drug event—supratherapeutic
drug level. Why?
Failure to follow up on test result
Communication between providers and care team members
Inadequate supervision of falls risk patient
©2012 American Academy of Neurology
Case 3 Neurology patient admitted to the ICU for
status epilepticus
Patient seizing for several hours with a low valproic acid level
Valproate level was not being monitored and was dosed incorrectly
ICU team not aware of when to call neurology Neurology cross-cover had no sign out for “bed
check” or lab follow-up
©2012 American Academy of Neurology
Case 4
Patient presented to the ER with mental status change and found to have a pneumonia.
Neurology consulted because of strange eye findings.
Neurology resident recommended head CT in the ER but never looked at the scan.
Patient admitted to medicine for the pneumonia and never had head CT done until 24 hours later, which reveals an acute obstructive hydrocephalus.
©2012 American Academy of Neurology
Case 5 Patient admitted to stroke service with new
atrial fibrillation and put on warfarin.
Patient discharged to PCP for follow up. PCP never received notification of admission
and discharge recommendations, was not following INR, and also thought that patient was not a warfarin candidate because of falls.
Patient is readmitted for second stroke 30 days later with INR of 1.1, even though patient reported compliance with medication.
WHAT IS THE IMPACT OF MEDICAL ERROR ON THE HEALTH CARE
PROFESSIONAL?
©2012 American Academy of Neurology
Impact of Error on Caregivers Surgeons who believed they made medical errors 3 x
more likely to consider suicide (Archives of Surgery)
Survey by Amy Waterman of 3100 physicians• 92% reported a “near miss” or a minor error• 57% reported a serious mistake
• Of those who reported serious error2/3 reported anxiety about future error50% reported decreased job confidence and
satisfaction
©2012 American Academy of Neurology
How Do We Avoid Medical Errors? Recognize the most common errors and take steps to
avoid them• Review records, orders, admission and discharge information• Review orders and medications at times of transfer between
units• Review vital signs daily or more frequently as possible as these
are early signs of changes in clinical status• Review all test results in a timely fashion• Identify patients at risk for falls• Write clearly
©2012 American Academy of Neurology
How to Avoid Medical Errors? Review medication lists at EVERY appointment Have a formal sign-out or hand-off procedure Provide written communication to referring
providers in a timely fashion
©2012 American Academy of Neurology
How to Avoid Medical Errors?
Make sure there is a clear follow up plan• Provide appointment on discharge summary for patients
discharged from the hospital
Provide written information about medications or diagnoses
Discuss discharge planning with case managers early so that patients are not waiting extra days in the hospital for rehab therapy or home health services to be arranged
©2012 American Academy of Neurology
How to Avoid Medical Errors? All of these things take time. . .
BUT
In the end it saves time and resources by reducing complications, length of stay, and cost to patients and systems.
WHEN ERRORS OCCUR: WHAT COMES NEXT?
©2012 American Academy of Neurology
Disclosing Errors Required by the Joint Commission
Important elements of disclosure that matter most according to patients• Disclosure of all harmful errors• An explanation as to why the error occurred• How the error's effects will be minimized• Steps the physician (and organization) will take to prevent
recurrences
©2012 American Academy of Neurology
Disclosing Errors
Doesn’t mean you talk to the patient or family without stopping to think first
You should tell the truth, but tell it wisely
This means:• Not withholding key information• Providing factual information in a timely manner while
acknowledging if there is uncertainty about the course of events or the consequences of the error
• Speculation ≠ Truth
©2012 American Academy of Neurology
Disclosing Errors Wisely First and foremost, when an error happens take
care of the patient
Once the dust settles, get help• Physician or nurse supervisors (preferably both)
Get the facts--and sometimes that takes time• Was there a departure from a standard of care?• Was the patient harmed?• Was the error avoidable?
Don’t blame, point fingers, or gossip
©2012 American Academy of Neurology
Disclosing Errors Wisely Get advice if necessary from Risk
Management, the hospital attorney, or the ethics committee
Plan the disclosure—DON’T WING IT
The most skilled and responsible person should conduct the discussion• Should not be delegated to an intern or other
subordinate
©2012 American Academy of Neurology
Disclosure ≠ Liability Disclosure is simply a statement that an error
happened.
Liability requires: • Negligence—departure from standard of care• Damages—i.e., the patient was harmed• Proximate cause—the harm resulted from the departure from
the standard of care
©2012 American Academy of Neurology
Summary Be aware of the potential for errors across all
environments and systems in which patients are cared for
Communication is key! Remove tubes/lines as early as possible Practice preventive medicine
• e.g., DVT prophylaxis
©2012 American Academy of Neurology
References1. Nightingale, Florence. Notes on Hospitals. London: Longman,
Green, Longman, Roberts and Green, 1863. 2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events
and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370–7.
3. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australia Health Care Study. Med J Aust 1995;163:458–76.
4. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press, 1999.
5. Leape L, Lawthers AG, Brennan TA, et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.
6. Layde, P. M., Meurer, L.N., Guse, C., Meurer, J. R., Yang, H., Laud, P., Kuhn, E.M., Brasel, K.J., & Hargarten, S.W. Medical Injury Identification Using Hospital Discharge Data. Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication Nos. 050021 (1–4). Vol. 2;119–132.
©2012 American Academy of Neurology
References
7. Balthasar LH, Keohane C, Seger DL et al. Cost of adverse drug events in community hospitals. Jt Comm Jour on Qual and Patient Safety 2012; 38:120-126
8. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review. Arch Intern Med 2003 Jun 23;163(12):1409–1416.
9. Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med 2006;166:1585-1593.