© 2012 American Academy of Neurology Patient Safety 101 for Neurologists.

©2012 American Academy of Neurology

Patient Safety 101 Patient Safety 101 for Neurologistsfor Neurologists


Overview The history of patient safety Situations that lead to medical errors Case studies How do we avoid medical errors


Patient Safety: The History

Hippocrates – “Primum Non Nocere”Hippocrates – “Primum Non Nocere”• BeneficenceBeneficence• Non-malfeasanceNon-malfeasance

Florence Nightingale Florence Nightingale • ““It may seem a strange principle to It may seem a strange principle to

enunciate as the very first requirement in enunciate as the very first requirement in a Hospital that it should do the sick no a Hospital that it should do the sick no harm.”harm.”


The History of Patient Safety Post-World War II

• Modern advances in the ability of medicine to help were accompanied by a corresponding increase in the ability to do harm

Studies of the impact of medical errors began to appear in late 1980s to early 1990s

Harvard Medical Practice StudyReviewed >30,000 charts from randomly selected patients in acute

and non-acute hospitals in New Yorko 3.6% of hospitalized patients experienced

adverse events resulting in harmo 70% of these events resulted in disability lasting

less than 6 months, 13.6% resulted in death, 2.7% permanent disability


The History of Patient Safety

Quality of Australian Health Care Study in 1995

• Placed greater emphasis on quality of care than negligence, i.e., could the adverse event be prevented?

• Reviewed >14,000 charts from 28 hospitals 16.6% of hospitalized patients experienced adverse events

o 77.1% of those had disability lasting less 12 monthso 13.7% with permanent disabilityo 4.9% ended in death

51% of the adverse events were considered preventable



In early 1995 an epidemic of errors erupted

• Michigan --a surgeon performing a mastectomy on a 69-year-old patient removed the wrong breast

• New York--a woman died when a doctor mistook her dialysis catheter for a feeding tube and ordered food to be pumped into her abdomen

• Tampa --a 51-year-old diabetic had the wrong foot amputated and a 73-year-old retired electrician died when a therapist mistakenly disconnected his ventilator



Institute of Medicine Report “To Err is Human”• Landmark paper published in 1999

Estimated incidence of patients who die in hospital due to preventable medical error

Was the springboard for emphasis on patient safety, quality improvement initiatives, and ultimately pay for performance


What is Medical Error?

Definition according to IOM• Failure of a planned action to be completed as intended or the

use of a wrong plan to achieve an aim

• Examples: adverse drug eventssurgical injuries and wrong-site surgeryrestraint-related injuries or deathfallspressure ulcers


The History of Patient Safety: IOM report “To Err is Human”

Medical error is the 8th leading cause of death in the US.

Medical errors cause 98,000 deaths per year.

More people die from medical error than from breast cancer, HIV, or MVAs.

John

These are figures which are not "intuitive" for many physicians. Are more details available about where these came from?


Types of Error Diagnostic

• Failure to order appropriate test• Delay in diagnosis• Failure to act on results or monitoring

Treatment• Error in the performance of an operation, procedure, or test• Error in administering the treatment• Error in the dose or method of using a drug

Preventative• Failure to provide appropriate monitoring or follow-up• Failure to provide prophylactic treatment

Other• Failure of communication• Equipment failure• Other system failure

John

This is good clarifying information.

USA TODAYThursday, June 28, 2001

USA TODAYThursday, June 28, 2001

Hospital mistakes must be disclosed

Accreditation at risk if patients aren’t told

By Robert DavisHospitals must now tell patients and their families when they have been hurt by a medical error, according to nationwide standards that take effect Sunday.

The standards by the nation’s leading health care accrediting agency are the first to hold hospitals accountable for a higher level of patient safety. …


How Unsafe is Healthcare??

Deaths per 100 million hours

Being pregnant 1Traveling by train 5Working at home 8Working in agriculture 10Driving 50Working in construction 67Being hospitalized 2000

John

As discussed at the meeting: can't this figure be explained by the fact that hospitals are where people die from their diseases (not on trains, working at home, driving, etc). This figure does not clearly demonstrate that the deaths were due to negligence.


Cost of Medical Error Estimated direct cost of medical error in US $17 billion

Preventable adverse events to Medicare patients estimated to cost in excess of $880 million annually

A study from 2008 revealed overall cost of medical error in the US to be >$19.5 billion• Total cost per error approx. $13,000• >2500 avoidable deaths• >10 million days of lost productivity at work, costing $1.1 billion in

short-term disability claims


Cost of Most Common Medical Errors

Event Number of injuries 2008

% considered due to error

Medical cost per event

Total cost per event

Pressure ulcers 394,699 >90 $8730 $10,288

Post-operative infections

265,995 >90 $13,312 $14,458

Mechanical complication of device, implant or graft

268,353 10-35 $17,709 $18,771

Hemorrhage complicating procedure

156,433 35-65 $8,665 $12,272


Why is Healthcare Prone to Error?

Multiple and varied interactions with technology

Many individuals involved in care Multiple hand-offs High acuity of illness Distracting work environment Rapid, time-pressured decisions High volume, unpredictable patient flow Multiple step processes


Why is Patient Safety Important to Me?

It can save lives It can make YOU a better physician It is part of every hospital plan – no matter where

you work Focused programs are required by the Joint

Commission It is a required part of resident education

curriculum by the ACGME and RRC

John

Perhaps the last bullet point could read: "For these reasons it is a required part of ....." This would lessen the impression that it's important to me because I HAVE to do it.


How Does This Affect Neurology?

Many patient groups at risk• Stroke patients with many comorbid illnesses

Potential for drug interactionsHigh risk for falls

• Seizure patients with poor compliance or complex regimens

• Parkinson’s patients and dementia patientsSignificant cognitive impairment may result in

medication errorPhysical disabilities may increase risk of falls and

injury

John

Ischemic Stroke patients' risk for hemorrhage is greatly subject to errors, such as giving tPA when exclusions are missed, giving wrong dose of tPA, not following up tPA with timely CT scans, starting heparin too early after tPA. The slide could further explain "many comorbid illnesses.." Seizure patients: AED adverse effects, including doseage errors in addition to the many allergic and metabolic effects. Parkinson's and dementia - adverse effects of meds, including


Of the 300 neurologic lawsuits requiring a pay out in 2004, most common diagnoses:

Disc disorder Stroke Headaches/migraine Seizure Cancer Meningitis Paralysis Aneurysm

John

could add to the slide that these were for missed or mis- diagnoses.


National Academy of Science’s Institute of Medicine (IOM)

In 2001, the IOM laid out six dimensions of quality for health care.

According to the IOM, health care should be• Safe • Effective• Patient-centered• Timely• Efficient • Equitable


Patient Safety and Quality Improvement Act of 2005

Signed into Law 7/29/05 Nationwide Goals

• “To encourage the voluntary reporting of medical errors”• Report to “Certified Patient Safety Organizations”

Many providers fear repercussions • Act provides federal legal privilege and confidentiality protection


Location of Patient Safety Organizations by State


Joint Commission Goals

Improve the accuracy of patient identification• “NEVER” events

Improve the effectiveness of communication among caregivers

Improve the safety of using medications

Reduce the likelihood of patient harm associated with the use of anticoagulation therapy

Reduce the risk of health care-associated infections


Joint Commission Goals

Accurately and completely reconcile medications across the continuum of care

Reduce the risk of patient harm resulting from falls

Encourage patients’ active involvement in their own care as a patient safety strategy

Recognize and respond to changes in a patient’s condition

Crossing the Quality Chasm– IOM report• IOM was supposed to be balanced

“…to strike a balance between regulatory and market-based initiatives, and between the roles of professionals and organizations”

• But it was compliance-heavy“…to create sufficient pressure to make errors so costly in terms of ability

to conduct business in the marketplace, market share and reputation that the organization must take action”

JCAHOJCAHOEstablish disease -specific

care performance indicators and mandatory reporting for accreditation

High quality SAFE patient

careGovernmentGovernment

Monitor providerorganizations through

mandatory and voluntaryreporting EmployersEmployers

Provide incentivesto providers that use

tools to increase safety.

ProvidersProvidersImplement tools that supportclinical decision making and

prepare for new reporting requirements.

PayorsPayorsProvide incentives to

providers that use tools to increase safety and can

demonstrate performance


“Traditional” Patient Safety

Honored traditional teaching Blame… Shame… Denial… Errors are caused by…

Time-honored solutions to error? Anger… Shoot the messenger… Work harder…Try harder… Blame the system…


“Culture”

The system of shared beliefs, values, customs, behaviors, and artifacts that the members of that society use to cope with their world and one another,

AND

… that are transmitted from generation to generation through learning.


“Culture of Safety”

• Acknowledges high-risk, error-prone nature of modern health care

• Shared acceptance of responsibility for risk reduction

• Encourages open communication about safety concerns in non-punitive environment


“Culture of Safety”

• Facilitates reporting of errors and safety concerns

• Learns from errors and redesigns safer systems

• Ensures that organizational processes, goals, and rewards are aligned with improving patient safety

MOST COMMON THINGS THAT CAN RESULT IN HARM TO PATIENTS

#1 MEDICATION ERRORS


1. Medication Errors

Occur frequently in hospitals• Approximately 2% of admissions experienced preventable Adverse

Drug Event (ADE)• Estimated increased cost $5000 per patient• ADEs cost about $5.6 million per hospital annually

Average cost per ADE in tertiary hospital $3244 with increased length of stay (LOS) of 2.2 days

Average cost per ADE in community hospital $3420 and increased LOS of 3.1 days


Medication Errors Most common medications associated with harm

• Anticoagulants• Antidepressants• Antipsychotic medications• Cardiovascular drugs• Analgesics


Predictors of ADEs Cannot solely be predicted based on patient factors or

drug types

Some associated risks:• Older age• Polypharmacy• Severity of illness


Medication Errors:

What can you do to reduce error or potential harm?

Check your orders for accuracy of dosingCheck medication interactions

Ask specifically about herbals and OTC productsCheck medication side effects and ask the patient about these on

subsequent visitsCheck to see that the patient is receiving the medication as

prescribedEncourage patients to bring in written listsUse EHR

#2 POOR COMMUNICATION


2. Poor Communication

In an average 4-day hospital stay, a single patient may encounter up to 50 different hospital employees

More than 1/5 of patients reported hospital system problems• Staff providing conflicting information• Not clear who the physician responsible for their care is


Poor Communication

With ineffective communication, great potential for harm• Lack of critical information• Misinterpretation of information• Overlooked change in status• Unclear orders over the phone

Communication errors identified as the root cause of sentinel (“Never”) events reported to the Joint Commission from 1995 to 2004


Barriers to Effective Communication

Hierarchical differences Inter-professional and intra-professional rivalries The health literacy of the patient Differences in language and jargon Cultural differences Generational differences

John

To emphasize and expand on issues of health literacy, you might want to add a add a bullet point on health literacy to replace the final 3 bullet points and add a separate slide, which I have inserted as the next slide.


Barriers to Effective Communication Despite your best efforts to communicate and your

belief that your have communicated effectively, more patients than you may realize don’t understand what you think they understand.

Rarely will patients reveal limitations in their understanding because they are embarrassed to do so.


Barriers to Effective Communication

Health Literacy - Factors affecting patients’ ability to understand

• Ability to read • Ability to understand English• Ability to understand medical “lingo”• Cultural / ethnic views of cause and treatment of

disease• Complexities of health care system


What can we do to improve communication within the health care team?Ensure that the information is conveyed between staff

members at shift changes.Written sign out including diagnosis, clinical status of patient,

pending results, key test results, allergies, CODE status, and “what to do if…”

If possible, bring the nurse into the room to demonstrate the current findings and specific things that you want to be notified about.

Document the teaching and follow-up. ASSUME NOTHING!


What can we do to promote effective communication with our patients? Speak in plain everyday terms– avoid medical jargon Use teach-back methods When possible utilize pictures or diagrams Provide written information or handouts Make every attempt to use a medical translator for

those patients who are non-English speakers


3. Infection Resulting from Lines and Tubes

Don’t use a Foley catheter unless it is absolutely necessary.

Lines should be dated and checked daily Lines should be removed as early as possible,

and if there is ANY sign of infection

As of 2009, CMS and some insurance companies will not pay for infections that develop once a patient is in the hospital


4. The Patient is Not Sufficiently Monitored

Patients may need frequent vitals monitoring, telemetry, serial lab testing depending on their condition

No one will fault you for being “overly cautious”


5. Handwriting Errors in misinterpretation of written orders

account for a large percentage of inpatient mistakes.• Avoid use of trailing zeros

Use 5mg not 5.0mg• Use leading zeros

0.5mg

Standardized order sets are used to help decrease orders of OMISSION.• However may increase orders of COMMISSION due to

duplication of tests or inappropriate medications/tests

Use of electronic health record systems can reduce errors caused by handwriting


6. The Diagnosis is Not Clear A wrong diagnosis is made because of failure to order

the appropriate test

Always evaluate for life-threatening processes that require immediate attention (stroke, myocardial ischemia, pulmonary embolism, intracranial hemorrhage) as appropriate

Review all test results in a timely fashion to ensure that patients are treated appropriately

Who will notify the patient about their test results? How will they be notified?


7. New Information is Ignored

Lab results in clinic resulted but not reviewed or patient not notified of result

Additional history from patient or family

A patient admitted for one thing may develop a new problem while hospitalized • (e.g., patient with a stroke develops an MI)


8. The Patient Who Needs Frequent Blood Monitoring: Diabetes and Anticoagulation

Insulin dosing errors in patients who are not eating Glucose fluctuations in patients who have

infections/stress of illness

Increased risk for bleed in anticoagulated patients Interactions with other medications

• Ex. Many drugs interact with warfarin and may cause INR to increase or decrease

• Ex. Antibiotics may interact with and alter levels of anti-epileptic drugs

AND LAST BUT NOT LEAST. . .


THE PHYSICIAN WHO ASSUMES THAT ERRORS DO NOT OCCUR! If we carefully review our work, we are less likely to

make errors

We should avoid making the same mistakes over again- system and practice change

“If you don’t have time to do it right the first time, how are you going to have the time to go back and fix it later?”

CASE STUDIES


Case 1 Patient admitted to stroke service by night float

resident (or hospitalist). EKG ordered as part of standard order set.

EKG result not reviewed by the night float (hospitalist); signed out by phone to the day resident (or next shift) who has 4 new admits and forgets to check about the EKG.

Medicine consulted for HTN management 2 days later and notices EKG with evidence of MI on admit.


Case 1: Key Learning Points

Review all test results and history at time of admission and also transitions of care

Adequate handoffs and sign-out are critical, optimally are written

Communication between providers is best done face to face


Case 2

Neurology consulted for patient with delirium in ER

The patient has history of seizures. Lab tests reveal a phenytoin level of 65, and patient is ataxic on exam

Resident does not communicate situation to nursing staff• Patient is placed in room away from nursing station without

bedrails up, and no falls precautions noted.

Patient falls out of bed attempting to go to bathroom and suffers subarachnoid hemorrhage and subdural hematoma.


Case 2: Key Learning Points Recognition of adverse drug event—supratherapeutic

drug level. Why?

Failure to follow up on test result

Communication between providers and care team members

Inadequate supervision of falls risk patient


Case 3 Neurology patient admitted to the ICU for

status epilepticus

Patient seizing for several hours with a low valproic acid level

Valproate level was not being monitored and was dosed incorrectly

ICU team not aware of when to call neurology Neurology cross-cover had no sign out for “bed

check” or lab follow-up


Case 4

Patient presented to the ER with mental status change and found to have a pneumonia.

Neurology consulted because of strange eye findings.

Neurology resident recommended head CT in the ER but never looked at the scan.

Patient admitted to medicine for the pneumonia and never had head CT done until 24 hours later, which reveals an acute obstructive hydrocephalus.


Case 5 Patient admitted to stroke service with new

atrial fibrillation and put on warfarin.

Patient discharged to PCP for follow up. PCP never received notification of admission

and discharge recommendations, was not following INR, and also thought that patient was not a warfarin candidate because of falls.

Patient is readmitted for second stroke 30 days later with INR of 1.1, even though patient reported compliance with medication.

WHAT IS THE IMPACT OF MEDICAL ERROR ON THE HEALTH CARE

PROFESSIONAL?


Impact of Error on Caregivers Surgeons who believed they made medical errors 3 x

more likely to consider suicide (Archives of Surgery)

Survey by Amy Waterman of 3100 physicians• 92% reported a “near miss” or a minor error• 57% reported a serious mistake

• Of those who reported serious error2/3 reported anxiety about future error50% reported decreased job confidence and

satisfaction


How Do We Avoid Medical Errors? Recognize the most common errors and take steps to

avoid them• Review records, orders, admission and discharge information• Review orders and medications at times of transfer between

units• Review vital signs daily or more frequently as possible as these

are early signs of changes in clinical status• Review all test results in a timely fashion• Identify patients at risk for falls• Write clearly


How to Avoid Medical Errors? Review medication lists at EVERY appointment Have a formal sign-out or hand-off procedure Provide written communication to referring

providers in a timely fashion


How to Avoid Medical Errors?

Make sure there is a clear follow up plan• Provide appointment on discharge summary for patients

discharged from the hospital

Provide written information about medications or diagnoses

Discuss discharge planning with case managers early so that patients are not waiting extra days in the hospital for rehab therapy or home health services to be arranged


How to Avoid Medical Errors? All of these things take time. . .

BUT

In the end it saves time and resources by reducing complications, length of stay, and cost to patients and systems.

WHEN ERRORS OCCUR: WHAT COMES NEXT?


Disclosing Errors Required by the Joint Commission

Important elements of disclosure that matter most according to patients• Disclosure of all harmful errors• An explanation as to why the error occurred• How the error's effects will be minimized• Steps the physician (and organization) will take to prevent

recurrences


Disclosing Errors

Doesn’t mean you talk to the patient or family without stopping to think first

You should tell the truth, but tell it wisely

This means:• Not withholding key information• Providing factual information in a timely manner while

acknowledging if there is uncertainty about the course of events or the consequences of the error

• Speculation ≠ Truth


Disclosing Errors Wisely First and foremost, when an error happens take

care of the patient

Once the dust settles, get help• Physician or nurse supervisors (preferably both)

Get the facts--and sometimes that takes time• Was there a departure from a standard of care?• Was the patient harmed?• Was the error avoidable?

Don’t blame, point fingers, or gossip


Disclosing Errors Wisely Get advice if necessary from Risk

Management, the hospital attorney, or the ethics committee

Plan the disclosure—DON’T WING IT

The most skilled and responsible person should conduct the discussion• Should not be delegated to an intern or other

subordinate


Disclosure ≠ Liability Disclosure is simply a statement that an error

happened.

Liability requires: • Negligence—departure from standard of care• Damages—i.e., the patient was harmed• Proximate cause—the harm resulted from the departure from

the standard of care


Summary Be aware of the potential for errors across all

environments and systems in which patients are cared for

Communication is key! Remove tubes/lines as early as possible Practice preventive medicine

• e.g., DVT prophylaxis


References1. Nightingale, Florence. Notes on Hospitals. London: Longman,

Green, Longman, Roberts and Green, 1863. 2. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events

and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370–7.

3. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australia Health Care Study. Med J Aust 1995;163:458–76.

4. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, DC: National Academy Press, 1999.

5. Leape L, Lawthers AG, Brennan TA, et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.

6. Layde, P. M., Meurer, L.N., Guse, C., Meurer, J. R., Yang, H., Laud, P., Kuhn, E.M., Brasel, K.J., & Hargarten, S.W. Medical Injury Identification Using Hospital Discharge Data. Advances in Patient Safety: From Research to Implementation. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ Publication Nos. 050021 (1–4). Vol. 2;119–132.


References

7. Balthasar LH, Keohane C, Seger DL et al. Cost of adverse drug events in community hospitals. Jt Comm Jour on Qual and Patient Safety 2012; 38:120-126

8. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: A systematic review. Arch Intern Med 2003 Jun 23;163(12):1409–1416.

9. Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words carefully: how physicians would disclose harmful medical errors to patients. Arch Intern Med 2006;166:1585-1593.

© 2012 American Academy of Neurology Patient Safety 101 for Neurologists.

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