Four Actions The Hospitalist’s Role in Patient Safety Mark B. Reid, MD Division of Hospital Medicine Denver Health Medical Center University of Colorado:

Four ActionsThe Hospitalist’s Role in

Patient Safety

Mark B. Reid, MDDivision of Hospital Medicine

Denver Health Medical Center

University of Colorado: GIM TMCFebruary 17, 2009Denver VA Hospital

To Err is Human: 1999 The flawed assumptions

Safety results from complexity

Errors are caused by bad people

This problem will be easy to fix

What has Worked?

1. Regulation: JCAHO

2. Reporting3. Teamwork

Training4. IT

The End of the Beginning: Patient Safety Eight Years After the IOM Report on Medical Errors. Robert M. Wachter, MD, 12th Annual Management of the Hospitalized Patient, San Francisco, CA October 23, 2008

Learning Objectives

1. Know when to wash your hands

2. Know who to call when an error occurs

3. Name one intimidating behavior

4. Name a common CPOE error

ACTIONS

1. Do JCAHO2. Report errors3. Be available4. Beware computer errors

1. When rounding on your patients, you foam or wash your hands:

A) neverB) before each patientC) after each patientD) whenever someone is watching

E) before and after each patient

1. When rounding on your patients, you foam or wash your hands:

A) neverB) before each patientC) after each patientD) whenever someone is watching

E) before and after each patient

What has Worked?

1. Regulation: JCAHO = rules2. Reporting3. Teamwork Training4. IT

Hand Hygiene

Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the

Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR

2002;51(No. RR-16)

Donskey and Eckstein 360 (3): e3, Figure 1 January 15, 2009

# Washes ≥ [# Patients] + 1

Practical Script for Hand Hygiene(hand washes are green arrows)

Time

Answer phone

P1

Check labs

P2 P3 P4 P5

Do JCAHO•National Patient Safety Goals: 2009

• Correctly identify patients• Read back telephone orders• “Do not use” abbreviations• Critical values• Standardized “hand-offs”• Look-alike/sound-alike drugs• Wash your hands• Reconcile medications @ admit and D/C• Identify patients at risk for suicide• Mark site/time out

Action 1

2. A patient is transferred to the floor from the MICU after a Tylenol overdose. What special step(s) should you take?

A) speak directly to the psychiatry consultantB) confirm that patient has a mental health holdC) assign patient to a sitter roomD) check his bagE) all of the above

2. A patient is transferred to the floor from the MICU after a Tylenol overdose. What special step(s) should you take?

A) speak directly to the psychiatry consultantB) confirm that patient has a mental health holdC) assign patient to a sitter roomD) check his bagE) all of the above

What has Worked?

1. Regulation: JCAHO = rules2. Reporting3. Teamwork Training4. IT

The Promise of Error Reporting:Safety in Air Travel

Joint Commission:National Patient Safety Goals

JCAHO Root Cause Analysis

• Hospitals obliged to report events to JCAHO• 42 reports covering “the worst” errors: PCA by proxy, delays in treatment, prevention of ventilator associated death• Example: 675 inpatient suicides reported as sentinel events• Sentinel Event Alert: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/

JCAHO Root Cause Analysis:Inpatient Suicide

• Incomplete suicide risk assessment at intake

• Failure to identify a contraband

• Incomplete communication among caregivers.

• Assignment of the patient to an inappropriate unit or location

The case of the pills in the bag

Report Errors Call Risk Management for “Never Events”

Wrong side/site surgeryAir embolismPatient suicideDeath from medication errorDeath from hypoglycemia (<60)Stage 3 or 4 pressure ulcerDeath or severe disability from a fall

National Quality Forum Serious Reportable Events in Healthcare 2006 Update

Action 2

3. A nurse tells you he noticed a patient was unsteady on her feet. The way you respond to this information could save another patient’s life.

A) yesB) no

3. A nurse tells you he noticed a patient was unsteady on her feet. The way you respond to this information could save another patient’s life.

A) yesB) no

What has Worked?

1. Regulation: JCAHO = rules2. Reporting3. Teamwork Training4. IT

Crashing Flight Simulators

JCAHO

Behaviors that Undermine a Culture of

SafetyIntimidating and disruptive behaviors can foster medical errors

Staff within institutions often perceive that powerful, revenue-generating physicians are “let off the hook”

A few commit many but many commit a few

http://www.jointcommission.org/SentinelEvents/SentinelEventsAlert/sea_40.htm

Are You an Intimidator?

Reluctance or refusal to answer questions, return phone calls or pages

Use of condescending language or voice intonation

Impatience with questions

Verbal outbursts or physical threats

TEAMWORK

Sutker, James Baylor Medical Grand Rounds, 7/17/2007

“Thanks for letting me know. That is very important information. You should always feel free to tell me when you notice anything.”

The Correct Response to the Nurse

Be Available

Listen and respect staff opinions

Be approachable and available

Don’t be an intimidator

Action 3

4. Do computers increase safety?

A) yesB) no

4. Do computers increase safety?

A) yesB) no

What has Worked?

1. Regulation: JCAHO = rules2. Reporting3. Teamwork Training4. IT

New Errors in CPOE

New Errors in CPOE

Sutker, James Baylor Medical Grand Rounds, 7/17/2007

1. Wrong patient selected2. Loss of chart personality3. Warning desensitization4. Order set ignorance

Beware Computer Errors

1. Is this the right patient?

2. Look up drug doses, especially for infrequently used medicines

3. Be redundant—talk to a human being!

Action 4

Learning Objectives

1. Know when to wash your hands

2. Know who to call when an error occurs

3. Name one intimidating behavior

4. Name a common CPOE error

Did you learn anything?

ACTIONS

1. Do JCAHO2. Report errors3. Be available4. Beware computer errors

Questions?