The Disruptive PhysicianThe Disruptive Physician
Federation of State Physician Health ProgramsFederation of State Physician Health Programs
2010 Annual Meeting2010 Annual Meeting
Doris C. Gundersen, MD Medical Director
Colorado Physician Health Program
Sentinel EventsSentinel Events
Defined by The Joint Commission as:
“Any unanticipated event in a healthcare setting resulting in death or serious physical injury or psychological injury to a person or persons not related to the natural course of the patient’s illness.”
Examples of Sentinel EventsExamples of Sentinel Events
Loss of limb or gross motor functionInfant abduction or d/c to wrong familyUnexpected death of full term infantSevere neonatal jaundice (bili > 30mg/dl)Surgery on wrong patient or body part
Examples of Sentinel EventsExamples of Sentinel Events
Object left in body post operativelyRape in continuous care settingSuicide in a continuous care settingHemolytic transfusion reactionRadiation to wrong area or 25%> than RX
Sentinel EventsSentinel Events
Causal Factors are analyzedSystems and processes are reviewedIndividual performance not reviewedRoot cause analysis performedAction Plan for improvements implementedAccredited organization reports to JC ≤ 45 days
Advantages of Reporting Advantages of Reporting Sentinel EventsSentinel Events
Contributing to database (track negative trends)
Dissemination of information for prevention
Joint Commission association serves to reassure the public and demonstrate the priority of patient safety
Joint CommissionJoint Commission
In its root-cause analysis of sentinel events, the Joint Commission traced 70 percent back to communication failures.
We have strived to improve patient care through technology.
The human factors are also crucial
Joint Commission, Issue 40Joint Commission, Issue 40July 9, 2008July 9, 2008
Defined Disruptive Behavior as a Sentinel EventRecognition that disruptive behavior can:
– Foster medical errors– Contribute to poor patient satisfaction– Contribute to preventable adverse outcomes– Increase the cost of care (including malpractice)– Lead to turnover/loss of qualified medical staff
Joint CommissionJoint Commission
Goal of including Disruptive Behavior as a Sentinel Event:
– Reform health care settings to address the problem There is a history of tolerance and indifference
– Promote a culture of safety– Improve the quality of patient care by improving the
communication and collaboration of health care teams
Joint Commission RequirementsJoint Commission Requirements
Hospitals establish a formal Code of Conduct
Leadership creates a process for reporting, evaluating and managing disruptive behavior
Joint Commission Joint Commission RecommendationsRecommendations
Educate all team members about professionalism
Hold all team members accountable for modeling desirable behaviors
Enforce the code consistently and equitablyNonconfrontational intervention strategiesProgressive discipline