Intern Survival Series Lecture #4 Preventing Medical Error As an - - PowerPoint PPT Presentation

Shaping the Future of Healthcare | www.thewrightcenter.org

Intern Survival Series Lecture #4

Preventing Medical Error As an Intern

Shaping the Future of Healthcare | www.thewrightcenter.org

Objectives

• After participating in this lecture, you should

be able to:

– Identify important steps in the anatomy of medical errors – Be able to identify the important places where you as an intern can decrease medical error – Identify the importance of an appropriate medical reconciliation and how to avoid pitfalls – Identify the importance of comprehensive signout and how to avoid pitfalls

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A Brief Note

• This lecture series is not meant to be all inclusive
• r totally comprehensive to all of medicine
• It is not meant to supersede clinical judgment
• It is not meant to replace daily reading or bedside

teaching

• It is meant to act as a starting point for which to

grow from as new primary care physicians

• It is a tool to help you survive the your new job

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Warning Tags Precipitated by Human Error

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Warning Tags Precipitated by Human Error

Shaping the Future of Healthcare | www.thewrightcenter.org

Warning Tags Precipitated by Human Error

Shaping the Future of Healthcare | www.thewrightcenter.org

Warning Tags Precipitated by Human Error

WARNING: Never use a lit match or open flame to check fuel level

Shaping the Future of Healthcare | www.thewrightcenter.org

Warning Tags Precipitated by Human Error

Shaping the Future of Healthcare | www.thewrightcenter.org

Warning Tags Precipitated by Human Error

Shaping the Future of Healthcare | www.thewrightcenter.org

Medical Warning Tags

• Do not give patient’s organs they are not

suppose to receive

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Medical Warning Tags

• Do not give pregnant

women medications that can cause birth defects or abortion.

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Medical Warning Tags

• Do not give colleagues wrong or incomplete

information of patients they will be caring for

• Do not continue patient medications that they

are not prescribed

• Do not start medications that are not indicated

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Wrong-Patient Medication Errors Examined by the Pennsylvania Patient Safety Authority

• June 3rd, 2o13
• Over 800 wrong-patient medication errors

were reported to the Pennsylvania Patient Safety Authority in a six-month period

• Insulin, heparin, vancomycin were the three

most common medications involved

• 30% of the errors were associated with high-

alert medications

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Medical Error

• Occurs when:

– a health-care provider chooses an inappropriate method of care – improperly executes an appropriate method of care.

• Medical errors are often described as human

errors in healthcare

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To Err is Human

• Landmark Report
• Released in 1999 by the

Institute of Medicine (IOM)

• revealed that between 44,000

and 98,000 people died each year in US hospitals due to medical errors.

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To Err is Human

• Astounding numbers
• Equivalent of three fully loaded

jumbo jets crashing and killing everyone onboard every other day

• Report called for a swift

reduction of medical errors in the United States.

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Where are we now

• After 14 years

– Medical Errors are still very high – Numbers are still under reported

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Sentinel Events

• Defined by The Joint Commission (TJC)
• “any unanticipated event in a healthcare

setting resulting in death or serious physical or psychological injury to a patient

• r patients, not related to the natural

course of the patient's illness”

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Sentinel Events

• Reporting

– Participation is necessary by the leadership of TJC & the systems under review (WCGME). – Causal factors are analyzed

• focusing on systems and processes
• not individual performance

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Sentinel Events

• Actions:

– May modify the organization's current accreditation status – Outcomes to system

• appropriate "measure of success”
• require follow-up survey within six months.

– A healthcare facility that fails to complete a root cause analysis of the sentinel event and action plan within the time frame can be placed on "Accreditation Watch" by the Joint Commission

• can be publicly disclosed

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Understanding Why Harmful Errors Occur

• ~95% percent of medical harm involves

conscientious, competent individuals involved in circumstances that lead to a catastrophic result

• These can be broken down into several factors

that impact human performance and increase risk for error

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Resident Medical Error

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– Factors in play before the harmful action takes place (pre-renal)

• Ex:

– Lack of sleep affecting judgment – Work fatigue from going over duty hours

– Factors that directly disrupt decision making (infra-renal)

• Ex:

– Lack of knowledge about particular disease state leads to Rx wrong or contraindicated medication – not reading up on patient’s ailment or keeping up to date with current guidelines leads to an inappropriate action or inaction

– Factors that directly affect decision execution (post-renal)

• Ex:

– Not following up on a correctly ordered test

Factors Contributing to Harmful Errors can be thought of like Renal Disease

Shaping the Future of Healthcare | www.thewrightcenter.org

Preventing Unsafe Acts in Healthcare

• In General:

– A “systems approach” to addressing medical error is taken

• Systems enact defenses to prevent accidents
• Member include:

– Institutions » WCGME, GCMC, VAMC, CHS – Organizations » ACP, ACOI, AMA, AOA – Teams » A,B,C, D, H – Technical » EHR, Lab results, imaging reports

Shaping the Future of Healthcare | www.thewrightcenter.org

Preventing Unsafe Acts in Healthcare

Focus is concentrated on conditions under which individual providers and care teams work – Defenses are designed into the workflow to avert errors – Focus is to minimize the conditions that lend to errors – Mechanisms are placed to lessen the blow of unsafe acts that may inevitably occur – In spite of this, errors still occur

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

Shaping the Future of Healthcare | www.thewrightcenter.org

How Can You Decrease Medical Error as an Intern?

• Comprehensive Medical Reconciliation

– Transition of care is the most dangerous time for a patient in any given system – Getting medications correct is easy when it is easy, and very hard when it is not

• Sign out

– Effective, comprehensive sign out is pinnacle to providing excellent patient care – Accurate patient information is crucial

Shaping the Future of Healthcare | www.thewrightcenter.org

Medication Reconciliation

• The process of comparing a patient's

medication orders to all of the medications that the patient has been taking.

• Done to avoid

–Omissions –Duplications –Dosing errors –Drug interactions

Shaping the Future of Healthcare | www.thewrightcenter.org

Medication Reconciliation

• It should be done at every transition of care in

which new medications are ordered or existing orders are rewritten

• Transitions in care include changes in setting,

service, practitioner or level of care.

– OP Medical Home to IP Hospital – IP to Rehab/SNF – Rehab/SNF to OP Medical Home

Shaping the Future of Healthcare | www.thewrightcenter.org

Medication Reconciliation

This process comprises five steps: 1) develop a list of current medications 2) develop a list of medications to be prescribed 3) compare the medications on the two lists 4) make clinical decisions based on the comparison 5) communicate the new list to appropriate caregivers and to the patient

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KNOW YOUR SYSTEM

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Example of a Good Sign out

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Example of a Not So Good Signout

Update?

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Preventing Unsafe Acts in Healthcare

• As you go through training, you will learn the

complexities and nuances of each system.

• Each system has are complicated and thorough

measures in place to prevent error

• Individual measures are beyond the scope of this

lecture.

• Be conscious of your actions.
• Be aware that even though many defenses are in place

and have lessened the total number of errors, errors still occur.