By Arnold Mackles, MD, MBA, LHRM
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Transcript
By Arnold Mackles MD MBA LHRM
The Sullivan Group
- Author of on line CME courses
- Volunteer member of Advisory Board
Innovative Healthcare Compliance Group Inc
- CME speaker
- Consultant
Americans and Healthcare
November 1999
Published report entitled
ldquoTo Err is Humanrdquo
Cited magnitude of medical error problem
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
Injury in 125 hospitalized patients
Estimated 44000-98000 deaths per year
Cost 17-29 billion $ per year
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
State mandated Florida Medical Board to require a two hour CME in ldquoPrevention of Medical Errorsrdquo
Course to cover
1) Root Cause Analysis
2) Error Reduction and Prevention
3) Patient Safety
4) Frequently Misdiagnosed Conditions
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
The Sullivan Group
- Author of on line CME courses
- Volunteer member of Advisory Board
Innovative Healthcare Compliance Group Inc
- CME speaker
- Consultant
Americans and Healthcare
November 1999
Published report entitled
ldquoTo Err is Humanrdquo
Cited magnitude of medical error problem
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
Injury in 125 hospitalized patients
Estimated 44000-98000 deaths per year
Cost 17-29 billion $ per year
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
State mandated Florida Medical Board to require a two hour CME in ldquoPrevention of Medical Errorsrdquo
Course to cover
1) Root Cause Analysis
2) Error Reduction and Prevention
3) Patient Safety
4) Frequently Misdiagnosed Conditions
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Americans and Healthcare
November 1999
Published report entitled
ldquoTo Err is Humanrdquo
Cited magnitude of medical error problem
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
Injury in 125 hospitalized patients
Estimated 44000-98000 deaths per year
Cost 17-29 billion $ per year
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
State mandated Florida Medical Board to require a two hour CME in ldquoPrevention of Medical Errorsrdquo
Course to cover
1) Root Cause Analysis
2) Error Reduction and Prevention
3) Patient Safety
4) Frequently Misdiagnosed Conditions
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
November 1999
Published report entitled
ldquoTo Err is Humanrdquo
Cited magnitude of medical error problem
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
Injury in 125 hospitalized patients
Estimated 44000-98000 deaths per year
Cost 17-29 billion $ per year
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
State mandated Florida Medical Board to require a two hour CME in ldquoPrevention of Medical Errorsrdquo
Course to cover
1) Root Cause Analysis
2) Error Reduction and Prevention
3) Patient Safety
4) Frequently Misdiagnosed Conditions
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Injury in 125 hospitalized patients
Estimated 44000-98000 deaths per year
Cost 17-29 billion $ per year
Kohn Corrigan and Donaldson Institute of Medicine To Err is Human Building a Better Health System National Academy Press2000
State mandated Florida Medical Board to require a two hour CME in ldquoPrevention of Medical Errorsrdquo
Course to cover
1) Root Cause Analysis
2) Error Reduction and Prevention
3) Patient Safety
4) Frequently Misdiagnosed Conditions
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
State mandated Florida Medical Board to require a two hour CME in ldquoPrevention of Medical Errorsrdquo
Course to cover
1) Root Cause Analysis
2) Error Reduction and Prevention
3) Patient Safety
4) Frequently Misdiagnosed Conditions
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Course to cover
1) Root Cause Analysis
2) Error Reduction and Prevention
3) Patient Safety
4) Frequently Misdiagnosed Conditions
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Adverse event
ldquoAn injury caused by medical management rather than the underlying condition of the patientrdquo
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Sentinel event
ldquoAn unexpected occurrence involving death or serious physical or psychological injury or the risk thereofrdquo
Joint Commission
httpwwwjointcommissionorgSentinelEvents Accessed January 22 2007
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Wrong site surgery 127 Retention foreign body 121 Delay in treatment 109 Suicide 101 Op post op complication 94
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Patient falls 86 Other unanticipated events 63 Medication errors 48 Criminal event 45
Perinatal death injury 36
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
1 Unintended Retention of a Foreign Body
2 Wrong-patient Wrong-site Wrong-procedure
3 Falls
4 Suicide
5 Delay in Treatment
6 Op Post Op Complications
The Joint CommissionrdquoSummary Data of Sentinel Events Reviewed by the Joint Commissionrdquo As of February 4 2016
httpswwwjointcommissionorgassets1182004-2015_SE_Stats_Summarypdf Accessed May 23 2016
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
2013 (N=887) 2014 (N=764) 2015 (N=936)
Human Factors Human Factors Human Factors
Communication Leadership Leadership
Leadership Communication Communication
Assessment Assessment Assessment
Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
The Joint Commission ldquo Sentinel Event Data - Root Causes by Event Typerdquo
httpwwwjointcommissionorgassets118Root_Causes_by_Event_Type_2004-2015pdf
Accessed April 30 2016
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Legibility of Orders
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
American Recovery and Reinvestment Act of 2008 (ARRA) - ldquoStimulus Billrdquo
Patient Protection and Affordable Care Act of 2010 (ACA)
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
HITECH Act (Health Information Technology for Economic and Clinical Health ACT)
Offered financial incentives to providers for adoption of health information technology
$44000 per practitioner
$11 million per hospital
Steinbrook R Health Care and the American Recovery and Reinvestment Act NEJM March 12 2009 Number 11 Volume
3601057-1060
httpcontentnejmorgcgicontentfull360111057 Accessed May 14 2010
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
75 of Eligible Professionals Participating
403000
25 of Eligible Professionals
Not Participating
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Office of the National Coordinator for Health Information Technology (ONC) ldquoUpdate on the adoption of health information technology and related efforts to facilitate the electronic use and and exchange of health informationrdquo Report to Congress Office of the Secretary United States Department of Health and Human Services October 2014 httpwwwtier3mdcommediaReport-to-Congress-2014pdf Accessed January 30 2015
92 of Eligible Hospitals Participating
4500 +
8
8 of Eligible Hospitals
Not Participating
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Year 2015 Annual CRICO Report
The Risk Management Foundation of the Harvard Medical Institutions Inc
ldquoCommunication failures linked to 1744 deaths in five yearsrdquo
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
23658 malpractice cases from 2009 to 2013 were evaluated
Identified 7149 cases where communication failures caused patient harm
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Failure of a nurse to inform surgeon of patient with post operative abdominal pain and drop in Hemoglobin
The patient later died of a hemorrhage
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Before her C-section a patient asked to have a tubal ligation
Instructions were not shared with the obstetrician on duty
Malpractice claim filed when she got pregnant again
Bailey M ldquoCommunication failures linked to 1744 deaths in five years US malpractice study findsrdquo STAT February 1 2016 httpwwwstatnewscom20160201communication-failures-malpractice-study Accessed February 13 2016
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Ambulatory Setting
ED 8
Inpatient Setting
44
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
48
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Miscommunication of the patientrsquos condition 26
Inadequate informed consent 13
Poor documentation 12
Unsympathetic response to pt complaint 11
Failure to read medical record 7
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Inadequate education re medications 5
Incomplete follow-up instructions 4
No or incorrect results given to patient 4
Miscommunication due to language 4
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Key provider-provider provider-patient
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Closed Malpractice Cases Communication error cases more frequently result in pay-outs
Payments are above average
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Closed Malpractice Cases Cases caused by errors in provider-provider communication more frequently result in pay-outs
Payments are higher than for
provider-patient communication cases
CRICO Strategies ldquoMalpractice Risks in Communication Failuresrdquo 2015 Annual Bernchmarking Report httpswwwrmfharvardedu~media0A5FF3ED1C8B40CFAF178BB965488FA9ashx Accessed February 13 2016
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Hospital Value-Based Purchasing (VBP) Program
Hospital Readmissions Reduction Program (HRRP)
Hospital Acquired Condition (HAC) Reduction Program
Medicaregov ldquoLinking Quality to PaymentrdquoHospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcomparelinking-quality-to-paymenthtml Accessed December 23 2014
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Pays for value or performance
Reimbursement based on - Results of specific quality measures
- Patient outcomes
Affects approximately 3000 hospitals in USA
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Each Domain is composed of various
ldquoMeasuresrdquo
of performance to be evaluated
Medicaregov ldquoHospital Value-based Purchasingrdquo Hospital Compare Official US Government site for Medicare httpwwwmedicaregovhospitalcompareDatahospital-vbphtml Accessed December 23 2014
Clinical
Clinical Process of Care
Patient Experience
of Care
Outcome
Efficiency
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Outcomes 25
Process 5
Clinical Care 30
Safety 20
Efficiency 25
Patient Experience
of Care 25
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
The HCAHPS Survey Hospital Consumer Assessment of Healthcare
Providers and Systems
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
ldquoThe HCAHPS survey is the first national standardized publicly reported survey of patients perspectives of
hospital carerdquo - CMS
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
HCAHPS Survey Administered randomly to a sample of discharged patients (48 hours - six weeks post discharge)
Methods of delivery mail telephone interactive voice recognition or combination
Asks 27 questions about hospital stay
httpswwwcmsgovMedicareQuality-Initiatives-Patient-Assessment-instrumentsHospitalQualityInitsHospitalHCAHPShtml Accessed April 22 2016
CMSgov ldquoHCAHPS Patients Perspectives of Care Surveyrdquo
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
HCAHPS Survey Dimensions Communication with nurses
Communication with doctors
Responsiveness of staff
Pain management
Communication about medications
Cleanliness quietness
Discharge information
Overall hospital rating
The Lake Superior Quality Innovation Network ldquo Underwtanding Value-Based Purchasingrdquo CMS Quality Improvement Organization Program
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Jenks Williams and Coleman
bull Medicare patients
bull 11855 discharges reviewed
bull 196 were re-hospitalized within 30 days
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Jenks Williams and Coleman
bull 34 were readmitted inside
of 90 days (10 were planned)
Estimated cost of $174 billion annually for unplanned readmissions
Jencks SF Williams MV Coleman EA ldquoRe hospitalizations among patients in the Medicare fee-for-service programrdquo N Engl J Med
2009 360(14)1418-28 httpwwwnejmorgdoipdf101056NEJMsa0803563 Accessed May 21 2013
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
ldquohellipRe hospitalizations are costly potentially harmful and often avoidablerdquo
- Institute for Healthcare Improvement (IHI)
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
The Affordable Care Act of 2010 (ACA) ldquoObama carerdquo
Established the ldquoHospital Readmissions Reduction Program (HRRP)rdquo
Required CMS to reduce payments to hospitals with excess readmission rates
Began October 1 2012
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Reimbursement is based on a ldquoreadmission ratiordquo
A hospitalrsquos readmission performance compared to the national average for a particular condition
Calculated over a 3 year period
25 patient case minimum
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-
Service-PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
HRRP began October 2012
3 applicable conditions Acute Myocardial Infarction (AMI)
Heart Failure (HF) and
Pneumonia (PN)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Additional conditions subsequently added
Acute Acerbations of Chronic Obstructive
Pulmonary Disease (COPD)
Elective Total Hip Arthroplasty (THA)
Total Knee Arthroplasty (TKA)
CMEgov ldquoReducing Readmissionsrdquo httpwwwcmsgovMedicareMedicare-Fee-for-Service-
PaymentAcuteInpatientPPSReadmissions-Reduction-Programhtml
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Staring in Fiscal year 2017
Coronary Artery Bypass Graft surgery
(CABG)
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
bull Interdisciplinary teams bull Coordination of care throughout bull Summary at discharge (in patientrsquos language)
bull Post discharge coordination and support (phone call visit 24-48 hrs home care out patient visits are arranged)
bull Patient surveys (for quality understanding of condition discharge instructions)
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Study Coleman and co workers
ldquoCare Transitions Interventionrdquo seniors
1) Control group - received routine hospital care
2) Intervention group
-Transition coach
- Patient participation encouraged
- Home visits follow up phone calls
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Coleman Study
Group 30 Day Rate 90 Day Rate
Intervention group 83 167
Control group 119 225
Coleman EA Parry C Chalmers S Min SJ ldquoThe care transitions intervention results of a randomized controlled trialrdquo
Arch Intern Med 2006 1661822-1828 httparchintejamanetworkcomarticleaspxarticleid=410933 Accessed May
21 2013
Readmission Rates
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples
BOOST - Better Outcomes for Older Adults through Safe Transitions
GRACE - Geriatric Resources for Assessment
TCM - Transitional Care Model
Project RED - Re-Engineered Discharge Bridge Model Care of Elders Guided Care
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
ldquoA process for identifying the basic or causal
factors that underlie variation in performance including the occurrence or possible occurrence of a sentinel eventrdquo - Joint Commission
httpwwwjointcommissionorgSentinelEventsse_glossaryhtmHTTP___JCSEARCHJCAHOORG_CGI_BIN_MSMFINDEXERESMASK=MssResENmskhttp3
Ajcsearchjcahoorgcgi-binMsmFindexe3Fhttp3Ajcsearchjcahoorgcgi-binMsmFindexe3FRESMASK3DMssResENmsk accessed January 23 2007
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Focuses on systems and processes
Not on individual performance
- Joint Commission
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Always ask ldquowhyrdquo
Then ask ldquowhyrdquo again
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Looks at special cause in clinical process
Looks at common causes in organizational process
- Joint Commission
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Identifies improvements that could decrease such events in the future
-Joint Commission
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Creates an ACTION PLAN
With recommendations to reduce the risk of similar future events
-Joint Commission
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
ACTION PLAN needs to outline
Implementation
Oversight
Pilot testing
Time lines
Means to measure effectiveness
- Joint Commission
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
bull Proximate cause
ndash Direct cause - Near origin of event
bull Underlying cause (Systems Root Cause)
- Far from event
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
How why did the ldquounsinkablerdquo sink
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
What were the
bull Proximate causes
bull Near the event
bull Underlying causes
(Systems Root Cause)
bull Far from event
Ship sank 1517 deaths
httpenwikipediaorgwikiRMS_Titanic
Accessed August 2 2010
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
bull Proximate causes
- Hit iceberg - Not enough life boats
bull Underlying causes (Systems Root Cause) - Steel hull weak - Bulkhead design - insufficient life boat
requirements -Communication (no binoculars) - Leadership (pressure to set
speed record)
Ship sank 1517 deaths
attlesJDisaster prevention lessons learned from the Titanic2001 Baylor University Medical Center April 14(2) 150ndash153
httpwwwncbinlmnihgovpmcarticlesPMC1291331 Accessed July 27 2010
httpwwwthinkreliabilitycomTitanicaspx Accessed July 22 2010
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
65
Titanic
sank
1500 Deathsss
Insufficient
number of
lifeboats
Ship hit
iceberg
Damaged
hull water
enters
Bulkhead not sealed water enters
Steel
buckled
Insufficient
regulations
Leadership decision
more deck space
Weak materials design
Bulkhead design
Turn
Rapid
Speed
Saw
iceberg
late
Speed
record
No Binoculars
Insufficient Communication
Training
Leadership
pressure
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Physician Insurers Association of America Rockville MD Data prepared by request 10515
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
ldquo
ldquoOperative amp Post - Op
Complicationsrdquo
64 cases reviewed
90 of cases were non-
emergent procedures
84 of cases resulted in
death
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Joint Commission Sentinel Event Alert Issue 12 Feb 4 2000
Operative and Post-Operative Complications Lessons for the Future
httpwwwjointcommissionorgSentinelEventsSentinelEventAlertsea_12htm
Accessed May 3 2008
58 occurred post - operatively
ldquoTwo-thirds of the hospitals
identified incomplete
communication among
caregivers as a root causerdquo
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Effective in reducing errors andhellip
Improving quality of care
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Haynes amp Gawande
NEJM
19 item ldquosurgical safety checklistrdquo (WHO 2008)
8 hospitals located around the world
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global
Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
3733 surgical patients before implementation of the checklist
3955 patients after implementation
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and Mortality
in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
After implementation
of the checklist
The rate of death decreased from 15 to 08
Surgical complications decreased from 11 to 8
Haynes A Weiser T Berry Whellip Gawande A et al ldquoA Surgical Safety Checklist to Reduce Morbidity and
Mortality in a Global Populationrdquo New England Journal of Medicine 2009 360491-499January 29 2009
httpwwwnejmorgdoifull101056NEJMsa0810119t=article Accessed September 23 2013
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
bull Research by Dr Hardeep Singh bull JAMA Internal Medicine 2013
bull Primary care cases bull 68 of 190 diagnosis were missed bull Most frequently missed Pneumonia (67 of total errors)
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
ldquoTypes and Origins of Diagnostic Errors in Primary Care Settingsrdquo
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Singh Research bull Process breakdowns involving the ldquopatient-practitioner clinical
encounterrdquo contributed to the error in almost 79 of cases bull Breakdowns
bull Obtaining an accurate history bull The examination bull Ordering appropriate diagnostic tests
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
bull Recommendation
bull Follow evidence-based protocols accepted guidelines for patients with pulmonary related signs symptoms or issues
Singh H Giardina T Meyer A et al Types and origins of diagnostic errors in primary care settingsrdquo JAMA Intern Med 20131ndash8 httparchintejamanetworkcomarticleaspxarticleid=1656540 Accessed February 27 2916
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Childhood diseases reappearing
Mumps 1057 cases in 2015 (CDC)
College campuses
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Yet many practicing physicians have never seen a case of Mumps
Providers must be prepared to diagnose and treat
CDC and State guidelines available
Centers for Disease Control and Preventions (CDC) ldquoAbout Mumpsrdquo httpwwwcdcgovmumpslabqa-lab-test-infecthtml Accessed March 3 2016 Centers for Disease Control and Preventions (CDC) ldquoMumps Cases and Outbreaksrdquo httpwwwcdcgovmumpsoutbreakshtml Accessed March 3 2016 Margason G ldquoIndiana University confirms 8 mumps cases on Bloomington campusrdquo Indy Star (USA Today Network) February 29 2016 httpwwwindystarcomstorynewsfox5920160229indiana-university-confirms-8-mumps-cases-bloomington-campus81134478 Accessed March 3 2016
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Approx 5 of all ED patients present with neurological symptoms
Typical symptoms dizziness headache weakness back pain and seizures
Failure to diagnose can result in patient harm
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Dugas evaluated non-trauma patients in the ED of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC)
Retrospective chart review
18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed
Although research concerning the misdiagnosis or delayed diagnosis of neurological conditions requires further attention and study the literature to date does reflect the importance of this issue For example a retrospective chart review by Dugas evaluated non-trauma patients in the Emergency Department of an urban tertiary care hospital for the misdiagnosis delay in diagnosis of spinal cord and cauda equina compression (SCC) The study revealed that 18 out of 63 or 29 of patients presenting with signs and symptoms of SCC were initially misdiagnosed Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
Dugas A Lucas J Edlow J ldquoDiagnosis of spinal cord compression in nontrauma patients in the emergency departmentrdquo Academic Emergency Medicine vol 18 no 7 pp 719ndash725 2011httponlinelibrarywileycomdoi101111j1553-2712201101105xfull Pope J Edlow J ldquoAvoiding Misdiagnosis in Patients with Neurological Emergenciesrdquo Emergency Medicine International Vol 2012 httpsdashharvardedubitstreamhandle1104659963410308pdfsequence=1 Accessed March 3 2016
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
2019 million opioid prescriptions dispensed in the USA (2009)
Sales of opioid analgesics quadrupled between1999 and 2010 (to hospitals pharmacies practitioners)
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy Critical Issues in the
Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency Medicine October 2012 Vol 60 No 4
httpwwwaceporgclinicalpolicies Accessed December 2 2012
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Mike Midgley RN JD MPH CPHRM FASHRM Florida Society of Healthcare Risk Management Webinar September 9 2015 wwwfshrmpsorg
259 Million
ldquoHealth care providers wrote 259 million prescriptions for painkillers in 2012 enough for every American adult to have a bottle of pillsrdquo
- CDC wwwcdcgovvitalsigns
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
The American College of Emergency Physicians
ldquoThe use of a state prescription monitoring program may help identify patients who are at high risk for prescription opioid diversion or doctor shoppingrdquo
Cantrill SMD (Chair) American College of Emergency Physicians Opioid Guideline Writing Panel ldquoClinical Policy
Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Departmentrdquo Annals of Emergency
Medicine October 2012 Vol 60 No 4 httpwwwaceporgclinicalpolicies Accessed December 2 2012
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
httpwwwe-forcsecom
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Centers for disease control and Prevention (CDC) ldquoIncreases in Drug and Opioid Overdose Deaths mdash United States 2000ndash2014rdquo Morbidity and Mortality Weekly Report (MMWR)January 1 2016 64(50)1378-82 httpwwwcdcgovmmwrpreviewmmwrhtmlmm6450a3htmfig2 Accessed May 30 2016
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
0
05
1
15
2
25
3
2007 2009 2011 2013
Deaths per 100000 People
Year
Centers for Disease Control and Prevention ldquoTodayrsquos Heroine Epidemic Infographicsrdquo httpwwwcdcgovvitalsignsheroininfographichtmluse Accessed October 5 2015
National Survey on Drug Use and Health 2002-2013
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Centers for Disease Control and Prevention (CDC) ldquoGuideline for Prescribing Opioids for Chronic Pain mdash United States 2016rdquo Morbidity and Mortality Weekly Report March 18 2016 65(1)1ndash49 httpwwwcdcgovmmwrvolumes65rrrr6501e1htm
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
US Food and Drug Administration Approval Process
bull Rigorous evidenced based evaluation and approval process
bull Insures that medications are effective and safe
bull Drug manufactures must reliably show that a drug can be produced in a safe accurate manner
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US
Food and Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforceme
ntActionsonUnapprovedDrugsdefaulthtm
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Drug must have ldquoExpected identity strength quality and purityrdquo
Label must meet standards to ensure that patients and providers alike can ldquounderstand a drug products risks and its safe and effective userdquo
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and
Drug Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActi
onsonUnapprovedDrugsdefaulthtm
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
bull Many medications continue to be marketed
illegally without proper FDA approval
bull Non approved drugs have not passed the
extensive FDA evaluation process
bull Therefore the prescribing dispensing
administering or using non-FDA approved
medications and devices could potentially pose
health risks
FDA ldquoUnapproved Prescription Drugs Drugs Marketed in the United States That Do Not Have FDA Approvalrdquo US Food and Drug
Administration Updated Feb 4 2014
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnforcementActionsonUnap
provedDrugsdefaulthtm
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Began in 2006
Undertakes measures to remove non-approved
medications from the US market
Policy attempts to remove the most dangerous and
risk-prone drugs as a priority
ldquoMarketed Unapproved Drugs- Compliance Policy
Guide (CPG)
FDA ldquoUnapproved Drugs Initiativerdquo US Food and Drug Administration
httpwwwfdagovDrugsGuidanceComplianceRegulatoryInformationEnforcementActivitiesbyFDASelectedEnf
orcementActionsonUnapprovedDrugsucm118990htm
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Ordering
Transcription
Dispensing
Administering
Monitoring
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Low Therapeutic Index - low ratio between toxic and therapeutic dose
Ex Digitalis
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Concentrated Electrolytes
Ex KCL
Ex NACL
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
IV Anticoagulants
Heparin
Warfarin
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Narcotics PCA
In combination with other meds
Benzodiazepines
Sedativehypnotics
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Insulin -Various Types
onset
duration
Concentrations
The American Society for Healthcare Risk Management (American Hospital Association)
Risk Management Pearls for Medication Error Reduction 2001(23-24)
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Chemotherapy
Highly Toxic Agents
The American Society for Healthcare Risk Management (American Hospital Association) Risk Management Pearls for Medication Error Reduction 2001(23-24)
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
List of High Risk Medications
wwwismporg
Institute for Safe Medication Practices ISMPrsquos List of High Risk MedicationshttpwwwismporgToolshighalertmedicationspdfAccessed November 26 2011
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
httpwwwjointcommissionorg
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Use 2 patient identifiers for
Obtaining blood
Giving meds
Procedures
Treatments
Label in presence of patient
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Develop procedures for reporting results
Definition of test procedure
Who to report to
Acceptable time for result
Procedure to manage results of critical tests
Measure of timeliness
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
ldquoReadbackrdquo phone verbal orders
ldquoReadbackrdquo test results
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Measure improve reporting time of results
Standardize communication ldquohandoffrdquo
JCAHO Patient Safety Goals httpwwwjointcommissionorgPatientSafetyNational PatientSafetyGoals Accessed January 18 2007
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Handoffs are ldquoPrime Timerdquo for communication errors to occur
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
SBAR
Used in nuclear submarines Adapted for healthcare use (Dr Leonard Kaiser Permanente Oakland CA)
Can be tailored for various types of handoffs
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
1) Situation ldquoWhat is going on with the patientrdquo
2) Background ldquoWhat is the clinical background or contextrdquo
3) Assessment ldquoWhat do I think the problem isrdquo
4) Recommendations ldquoWhat would I do to correct itrdquo
Pillow M Smith V (Editors) Joint Commission Resources Improving Hand-Off Communication 2007 P67
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Boston Childrenrsquos Hospital
Developed to improve house staff handoffs
Printed handoff form
Integrated into EMR
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April 29
2012httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
I ndash Illness severity
P ndash Patient summary
A ndash Action list for the next team
S ndash Situation awareness and contingency
plans
S ndash Synthesis and ldquoread-backrdquo
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
3 Month ldquobefore and afterrdquo pilot study
After implementation of I-PASS
- 40 reduction in medical errors (from 32 to
19)
- More time spent with patients (225 min24-
hr vs 122 min24 hr)
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Boston Childrenrsquos Hospital ldquoI-PASS Standardizing patient ldquohandoffsrdquo to reduce medical errorsrdquo Newsroom April
29 2012 httpchildrenshospitalorgnewsroomSite1339mainpageS1339P878html
After implementation of I-PASS
- Inclusion of patient ldquoTo Do Listrdquo went from
29 to 82
- Inclusion of ldquoMedication Listrdquo went from
3 to 100
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Universal Protocol Effective July 1 2004
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Pre-op verification process
Marking operative site
ldquoTime Outrdquo before starting
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed
September 24 2015
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Label on and off sterile field Syringes Cups Basins
Label all transferred solutions Med name strength quantity diluent volume
Expiration dates
Verify labels verbally visually
GOAL Label all medications medication containers and
other solutions on and off the sterile field in perioperative
and other procedural settings
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September
24 2015
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Reduce the
Unit-doses prefilled syringes or premixed IV bags
Approved protocols policies for use labs required
International Normalized Ratio (INR) for warfarin use
Programmable pumps for heparin
Provide patient education
The Joint Commission httpwwwjointcommissionorgstandards_informationnpsgsaspx Accessed September 24 2015
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
700000 ndash 1 Million hospitalized Patients fall each year
11000 hospital falls result in death each year
Currie Lrdquo Fall and injury prevention In Hughes RG ed Patient Safety and Quality An Evidence-Based Handbook for Nursesrdquo (AHRQ Publication
No 08-0043) Rockville MD Agency for Healthcare Research and Quality 2008 httpwwwahrqgovqualnurseshdbkdocsCurrieL_FIPpdf
Accessed May 26 2014
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Hospital Falls
30-35 result in injuries
LOS increased by 63 days
Cost per fall = $14056
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414 bull Wong C Recktenwald A Jones M et al ldquoThe Cost of Serious Fall-Related Injuries at Three Midwestern Hospitalsrdquo The Joint Commission Journal on Quality and Patient Safety Volume 37 Number 2 February 2011
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Joint Commission Center for Transforming Healthcare
7 US Hospitals
Identified causes of falls created targeted solutions gt intervention
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Examples of targeted solutions Utilizing a fall assessment tool
Partnering with patients (teach safety)
Hourly rounding
Video monitoring
Scheduled toileting
Patient sitters if necessary
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Results of Intervention
35 reduction in falls (4 falls 1000 pt days to 261 falls 1000 pt days)
62 reduction in falls with injury
(131 falls-injury1000 pt days to 050 falls-injury1000
pt days)
bull DuPree E Fritz-Campiz A Musheno D ldquoA New Approach to Preventing Falls With Injuriesrdquo Journal of Nursing Quality of Cqre AprilJune 2014 V e29 Issue 2 PP 99-102 bull Joint Commission Center for Transforming Healthcare ldquoFacts about the Preventing Falls With Injury Projectrdquo Joint Commission 414
Related Documents
