Medical Errors Prevention · 2018-04-03 · 2 Course Objectives • Produce effective documentation • Formulate a personal plan to prevent the spread of infection • Assist patients

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Medical Errors Prevention

Lisa Roberts, PT, MS, DPT, CSCSFlorida International University

August 25, 2015

Course Objectives

Following this presentation, participants will be able to . . . . . . .• Accept that medical error prevention is an

essential component of patient management• Define terminology related to medical error

prevention• Recognize the medical errors associated

with the practice of physical therapy• Based upon a patient case scenario, perform

a root cause analysis

Course Objectives

• Promote safety and develop a medical error reduction plan

• Describe how pharmacology related issues impact patient treatment and assessment

• Improve communication skills• Adapt physical therapy intervention to the

patient’s level of health literacy• Review the concepts of indications and

contraindications as related to patient care

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Course Objectives

• Produce effective documentation• Formulate a personal plan to prevent the

spread of infection• Assist patients to become self-advocates

Medical Errors

• 1995 Tampa, Florida. Patient with diabetes has the wrong leg amputated.

• 2003. Duke University. Patient dies after receiving a heart-lung transplant of the wrong blood type.

• 2007. California. Twin infants were given massive doses of heparin. The labels of the different doses of the drug looked very similar.

Chasing Zero: Winning the War on Healthcare Harm

• Discovery Channel• Chasing Zero Trailer

• http://www.youtube.com/watch?v=sSGyVwV5p7k

• Full Length Video• https://www.youtube.com/watch?v=MtSbgUuXdaw

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Medical Errors

Licensure requires a mandatorytwo hour course!!!!

Please . . . . . . . . . . . . . . . .• Sign the course registration sheet

• Name (please print legibly)• License Number (PT or PTA)• Credit will be posted on CE Broker

within two weeks

Board of Physical Therapy Practice 64B17-8.002

Requirements for Prevention of MedicalErrors Education

• Two contact hours• Study of root cause analysis• Error reduction and prevention• Patient safety• Medical documentation and communication• Contraindications and indications for

physical therapy management• Pharmacological components of physical

therapy and patient management

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Second Victims of Medical Errors

• Health care provider reactions to making a medical error

• Fear• Losing a job• Litigation

• Guilt • Shame• Lack of confidence

Physical Therapy Liability

• 2001 – 2010 Physical Therapy Liability Study by Healthcare Providers Service Organization (HPSO)

• “We firmly believe that knowledge is the key to patient safety”

• Section One has three components• Statistical Charts and Analysis• Risk Management Recommendations• Self Analysis Checklist


• 552 Claims• “The highest average paid indemnity

resulted from the closed malpractice claims that occurred in a hospital setting while the highest total paid indemnity resulted from closed claims that occurred in offices or clinics.”

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• Most Common Claims• Improper performance using therapeutic

exercise• Improper performance using a physical

agent• Failure to supervise or monitor

Claims Study

• 2001 – 2010 Physical Therapy Liability Study by Healthcare Providers Service Organization (HPSO)

• PDF available at the following web address . . . . . . . . . . .• http://www.hpso.com/Documents/pdfs/CNA_CLS_PTrepo

rt_final_011312.pdf

Alarming Statistics• The November 1999 report of the

Institute of Medicine (IOM) entitled To Err is Human: Building a Safer Health System highlighted the issue of medical errors and patient safety

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Alarming Statistics

• The report indicated that 44,000 to 98,000 people die in hospitals each year, the result of medical errors

• Medical errors are the eighth leading cause of death in the USA

• Estimated financial costs: $37.6 billion each year, $17 billion of those costs associated with preventable errors

Reference: Agency for Healthcare Research and Quality at http://www.ahrq.gov/

Medical Errors More Common

• New method for identifying hospital medical errors

• Global Trigger Tool (comprehensive review of hospital medical records)

• Actual error rate may be 10 times more than was previously indicated

• Report published in the April 2011 issue of Health Affairs

Medicare

• Grants bonuses to doctors and hospitals that report quality measures

• Medicare will not pay for “reasonably preventable” conditions related to medical errors. Included are incompatible blood transfusions, infections related to particular surgeries, or needing a second surgery to retrieve a sponge left behind. Also included are serious bed sores, injuries from falls, and urinary tract infections from catheters.

Reference: New York Times, October 1, 2008.

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New Medicare Penalties

• Hospital Acquired Conditions (HAC)• 721 hospitals with high infection rates

and other medical errors• Medicare payments lowered by 1%

over fiscal year October 2014 through September 2015

• Penalties estimated at $373 million• Teaching hospitals impacted greatly

Medicaid

• Aligning state Medicaid programs with the Medicare policy to refuse payment for certain preventable errors

• Concept of “never events”• Medicaid policy changes, effective

July 2012

Medicaid No Pay Events

• Foreign object retained after surgery• Air embolisms• Blood incompatibility• Stage III and IV pressure ulcers• Falls and traumas that produce fractures,

dislocations, crushing and other injuries• Catheter-associated urinary tract infections• Wrong surgery, wrong surgical site, surgery

on the wrong patient

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Medicaid No Pay Events

• Vascular catheter-associated infection• Manifestations of poor glycemic control• Surgical site infections • Deep vein thrombosis or pulmonary embolism

after total knee or hip replacement (with pediatric and obstetric exemptions)

• References• American Medical News (www.amednews.com)• Centers for Medicare and Medicaid Services

Institute of Medicine

• Emphasized that most medical errors are systems related, not individual negligence

• Focus should be on improving systems, not blaming individuals

• Research has indicated that system improvements can reduce error rates and overall quality of care

Prevention Initiatives

• Family Activated Safety Team• Family calls and receives an immediate response

• Keystone Project• Checklist

• Virginia Mason Medical Center• Patient Safety Alert

• Seven Pillars by the University of Illinois Hospital in Chicago led to investigations and specific improvements

• http://www.ahrq.gov/news/columns/navigating-the-health-care-system/071012.html

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Seven Pillars Steps• Report incidents that could harm patients• Investigate those cases and fix problems before an

error happens• Communicate when an error occurs, even if no

harm was done• Apologize and "make it right" by waiving hospital

and doctors' fees• Fix gaps in the system that can cause things to go

wrong• Track data from patient safety reports and see if

changes make things safer• Educate and train staff how to make care safer

Patient Wristbands

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Institute of Medicine

• Defines medical error as “the failure to complete a planned action as intended or the use of a wrong plan to achieve an aim.”

Types of Medical Errors

• Medication errors• Mishandled surgeries• Diagnostic error• Equipment failure• Infections, including nosocomial• Blood transfusion injuries• Misinterpretation of medical orders• Errors of omission

Physical TherapyErrors

• Diagnostic errors• Intervention errors• Lack of prevention• Communication failure• Equipment failure or misuse• Misuse of ancillary personnel

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Current Correctional Emphasis

• Establishing a root cause of the error• Correcting a systems failure• Avoiding future occurrences

Definitions

• Sentinel Event: An occurrence unplanned, not scheduled or anticipated, resulting in death, serious harm, or the risk for physical or psychological harm. Adverse event caused by the error.

• “Near misses”: Would have resulted in a sentinel event if chance or intervention had not occurred.

Definitions

• Adverse Event: An injury caused by the medical treatment or management that was not anticipated or planned during the medical care of a patient. Adverse events can be preventable or unpreventable.

• Adverse Drug Event: Death or injury from a wrong medication, wrong dosage, or from multiple pharmaceutical interactions/reactions.

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Definitions

• Overuse: Providing medical care that its use has potential for more harm than good.

• Underuse: Not providing a medical intervention that could have been helpful to the patient.

• Misuse: An intervention is scheduled but a preventable complication occurs and the intervention is not given the opportunity to work.

Question

You are the supervisor of the Physical TherapyDepartment. One of your PTs reported that she forgotto replace the patient’s restraints and the patientsubsequently pulled out his NG tube. After theincident was reported you realize that the departmentdoes not have any policies or procedures related topatient restraints. Using a Medical Errors perspective,what was the sentinel event?

A the patient pulling out the NG tubeB the PT forgetting to replace the restraintsC not having policies and procedures in placeD documenting the incident in the medical record

Definitions

• Root Cause Analysis: A process to study a situation, circumstances, or problem in a prescribed method to allow actual determination of the primary (root) cause in a sequence of events. Root cause analysis requires an investigation/review, collaboration, an action plan, implementation process, and follow-up for monitoring the effectiveness of the corrective action plan.

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Charles Vincent’s Framework for Categorizing the Root Causes of Errors

• Institutional• Regulations• Medicolegal environment

• Organization and Management• Financial issues• Policy standards and organizational goals• Organizational safety culture

• Work Environment• Staffing patterns and workload• Equipment issues• Administrative support


• Team• Written and verbal communication• Supervision and leadership• Seeking assistance

• Individual Staff Member• Knowledge and skill set• Motivation and attitude• Staff health

• Task• Use of protocols• Availability and accuracy of test results


• Patient• Complexity• Language and communication• Personality• Social issues

Reference: Understanding Patient Safety. RobertWachter. 2008. McGraw Hill Medical: New York.

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Question

Your patient weighs 315 pounds. Upon reading thepatient’s chart you discover that the patient fell lastnight during a Hoyer Lift transfer with one of thenursing assistants. The lift tipped over and thepatient fell. Fortunately the patient was not harmedduring this fall. You realize that the Hoyer Lift on that floor is weight rated to only 250 pounds. Using amedical errors prevention perspective, what do youbelieve was the root cause of this incident?

A written and verbal communicationB knowledge and skill set of the staff memberC staffing patterns and daily workloadD complexity of the patient’s condition

Framework for Root Cause Analysis

• What happened?• Why did it happen? • What were the causative factors?

• Human factors• Environmental factors• Equipment factors

• What systems are related to those factors?• Human resource issues• Communication• Environmental management• Leadership issues

Framework for Root Cause Analysis

• Analyze Data• Risk Reduction Strategies• Planned Action• Implementation Dates• Quality Measurements

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Failure Mode and Effect Analysis

• Assumes failure• Humans err often• Often beyond the individual’s control• Proactive, prospective approach• Systemic• Multidisciplinary team-based

approach

Case Study

A community hospital is starting a surgical bariatric program. Many of these patients will be referred to the physical therapy department for mobility training. The PT department currently does not have equipment suited for these potential patients. What would be a proactive approach to serving this patient population?

How can systems work to reduce medical errors?

• Simplifying processes• Improving communication• Increasing management support• Decreasing punitive punishment

environments• Instituting protocols, pathways, and

policies to support error reduction

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Important Question

How can we, while providing physical therapy, ensure our patient’s safetywhile reducing the opportunity formedical errors?

Prevention Strategies

• P Partnership of all Stakeholders• R Reporting Errors Without Fear• O Open-Ended Focus Groups• C Cultural Shift• E Education and Training Programs• S Statistical Analysis of Error Data• S System Redesign

Perspectives on Assessment of Physical Therapy Error in theNew Millennium by Judith Anderson and Elizabeth Towell.Journal of Physical Therapy Education, Winter 2002. Vol 16, No 3,54-60.


• Partnership of all Stakeholders• Clinicians, patients, students, faculty• Facilitate communication

• Reporting Errors without Fear of Punishment

• Offer incentives for reporting

• Open-Ended Focus Groups• Reduce secrecy• Discuss therapy protocols and problem areas

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• Cultural Shift•Open identification of errors•Participation in quality protocols•Differentiate between errors and ethics

• Education and Training Programs•Use error analysis to guide training


• Statistical Analysis of Error Data•Continuous process

• Systems Redesign•Adjust systems•Eliminate or decrease potential error

situations

Strategies for Preventing Medical Errors

• Establish a procedure for dealing with medical errors

• Increase organizational structure toward system responsiveness for medical error reduction• Simplify• Supportive and involved management• Improve effective communication

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Communication

• Verbal, non-verbal, and written• With rehabilitation colleagues• Interdisciplinary communication• Confidentiality• Patient education

•Informed consent•Health literacy

Health Literacy

• IOM indicated that nearly half of all adults have inadequate health literacy

• AMA health literacy video• http://www.youtube.com/watch?v=BgTuD7l7LG8

• Address the patient’s understanding• Use multiple informational methods• Effective Patient Education

• Explain, Ask, and Listen• Write it Down• Demonstration and Repetition

Communication

• Removing language barriers• Written home exercise programs in the

appropriate language

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Interprofessional Teamwork and Enhanced Communication

• Reduces medical error

• Improves patient outcomes

• Improves patient satisfaction

• Increases staff satisfaction

Case Study

A physical therapist is working in the hospital rehab gym. She has a new patient scheduled this morning. Upon chart review it is noted that the patient had a MVA and fractured both lower legs. He is currently NWB bilaterally. The therapist requests that the rehab tech transport the patient down to the gym. When the tech returns with the patient, she says that the nurses were very busy so she transferred the patient into the wheelchair. The tech reports that the patient did very well as he stood up from the bed and walked a few steps to the wheelchair.


• Standardize• Protocols• Policies and Procedures• Pathways

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• Increase technological support• Provide evidence-based treatment

Other Issues to Consider

• Pharmacological concerns (medication, chemotherapy, radiation, etc)

• Awareness of treatment protocols and precautions with different diagnoses

• Equipment and facility assessment• Documentation• Contraindications/Indications

Pharmacology Issues

• Awareness of the patient’s medications

• Potential side effects and interactions• Knowledge of how medication may

impact rehabilitation activities and/or exercise response

• Pain management issues• Contributory risk factor for falls• Allergic reactions (iontophoresis)

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Case StudyThe patient is a 73 year old male. His medical history is positive for myocardial infarction with stent placement, hypertension, and Type 2 diabetes. His current medications include: Lopressor (beta-blocker) 50 mg BID, Aspirin 325 mg QD, Diovan (angiotensin receptor blocker) 80 mg QD, and Zocor (statin drug) 20 mg QD. Patient also uses nitroglycerin tablets PRN. The patient reports no longer taking any medication for his diabetes per MD order. He also reports that he does not regularly monitor his blood glucose and has recently gained twenty pounds, mostly in the abdominal area. His physician has ordered physical therapy to address his exercise needs. The goal is promoting weight loss and decreasing the need to resume diabetes medication.

Allergies• Latex

• Gloves• Elastic exercise bands• Balloons

• Creams, lotions, etc.• Food• Insect bites

Physical TherapyExamination

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Case Study

Mr. G is 45 years old. He was referred to the outpatient physical therapy clinic for treatment of left shoulder pain. The therapist examines the shoulder and implements the PT plan of care. It is noted in the chart that Mr. G’s pain was unchanged following the treatment intervention. He is scheduled for therapy 3 times per week. The next day his wife calls to cancel his appointments as he was admitted into the hospital with a heart attack and underwent coronary bypass.

Treatment Protocols and Precautions

• Diagnosis specific precautions• Surgical protocols• Safety equipment, such as gait belts• Safety policies and procedures

Equipment

• Proper Use and Application• Equipment Inspections• Equipment Hygiene• Policies and Procedures

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Case Study

Mr. P is 28 years old. He is receiving treatment for his right knee (ACL repair). As part of your muscle re-education program with him you are using electrical stimulation. As you turn on the machine, the patient screams out in pain and accuses you of trying to shock him to death. You turn off the machine and remove the electrodes. As you place the machine next to the wall, another therapist walks by and states “Don’t use that machine, it’s broken. We’ll have to call the repairman.”

Facility Assessment

• Environmental approach• Equipment storage• Walking surfaces• Traffic pathways• Accessibility issues

Documentation

• Complete and Timely• Proper use of Abbreviations• Legible• Use of Electronic Documentation• Use of Forms• Verbal Orders• Incident Reports

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Documentation• Joint Commission abbreviations

“Do Not Use” list • Abbreviations in general

• AMA (American Medical Association)• AMA (Against Medical Advice)• PT (Physical Therapy)• PT (prothrombin time)

Electronic Health Records

• Improving the accuracy and clarity of medical records

• Making health information available and accessible

• Potential to reduce medical error

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Health Information Technology

• Computer Provider Order Entry (CPOE)

• Computer utilized to monitor dosage, allergies, drug interactions, etc

• Medication “Flight Simulator”• Checks for problems• Importance of simulation in health care

Computerized Provider Order Entry

• “Computerized provider order entry (CPOE) is an application that allows health care providers to use a computer to directly enter medical orders electronically in inpatient and ambulatory settings, replacing the more traditional order methods of paper, verbal, telephone, and fax. CPOE systems can allow providers to electronically enter medication orders as well as laboratory, admission, radiology, referral, and procedure orders. Strictly defined, it is the process by which providers directly enter medical orders into a computer application.”

Computerized Provider Order Entry

• Legible orders• Real time functionality• Clinical decision support systems• Medical error reduction• Agency for Healthcare Research and

Quality• https://healthit.ahrq.gov/key-topics/computerized-provider-order-entry

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Indications and Contraindications

• Diagnostic Issues• Treatment Protocols• Surgical Protocols• Manual Therapies• Exercise Programs• Physical Agents

Infection Control

• Hand hygiene• Use of protective equipment• Cleanliness and disinfection

techniques

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Empower PatientsAgency for Healthcare Research and Qualityhttp://www.ahrq.gov/consumer/20tips.htm

Speak Up™ Initiatives

• Speak up if you have questions or concerns

• Pay attention to the care you receive• Educate yourself about your illness• Ask a trusted family member or friend

to be your advocate• Know what medications you take and

why you take them

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Speak Up™ Initiatives

• Use a health care organization that has been carefully checked out for quality and safety

• Participate in all decisions about your treatment

• Reference: The Joint Commission• http://www.jointcommission.org/facts_about_speak_up_initiatives/

Any Questions?

• [email protected]

Thank You for Your Attention