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