Patient Safety CME Curriculum Patient Safety: The Other Side of the Quality Equation

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Patient Safety CME CurriculumPatient Safety
The Other Side of the Quality Equation

• Under a Grant from
• The Agency for Healthcare Research and Quality
• Principal Investigator
• Christel Mottur-Pilson, PhD
• Director, Scientific Policy
• ACP-ASIM

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Patient Safety The Other Side of the Quality
EquationSeven Modules in Ambulatory Care

• Systems
• The influence of systems on the practice of
  medicine.
• Cognitive Capacity
• Coping mechanisms under information overload and
  time pressures
• Communication
• Communication barriers, lack, and unclear
  communication
• Medication Errors
• Uniform dosing, look- and sound-alikes, forcing
  functions

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Patient Safety The Other Side of the Quality
EquationSeven Modules in Ambulatory Care

• The Role of Patients
• Patients as allies in patient safety
• The Role of Electronics
• Supportive products and processes
• Idealized Office Design
• Medical practice design to support patient safety

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Logistics

• CME To receive your CME, please fill out the
  usual forms
• Evaluation form
• CME form
• Research Grant Surveys
• Pre-CME assessment of knowledge level
• Post-CME assessment of knowledge level
• Six-month follow up to CME
• Virtual Patient Safety Electronic Community

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Cognitive Capacity

• Influence of systems on cognitive capacity
• Information processing
• Human factors
• Relationship of these 3 factors to patient safety

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Presentation Goals

• Understanding how cognition influences patient
  safety
• Awareness of the influence of cognition in a
  systems context via clinical cases
• Take home points to guard against cognitive
  lapses

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Humans as Information Processing Systems

• Variables affecting information processing
• Overall systems context
• Attention
• Perception
• Mindset

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Systems Context

• System constraints
• Time pressure
• Conflicting goals
• Insurance companies
• System facilitators
• Discussion with colleagues
• Point of service decision aids

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Attention

• Multiple theories of attention
• Common sense perception of attention
• Relationship between perception, mindset and
  attention

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Perception or Pattern Recognition

• What is perception?
• What is pattern recognition?
• The role of these two constructs in understanding
  patient safety

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Cognitive Structures

• Working memory (WM)
• Knowledge base (KB)

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Mindset

• Knowledge in context
• Mindset in cognition vs. mindset as bias
• Goal conflicts

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Decision Making

• Selection of goals and tasks
• Information processing
• Limited workspace of the working memory
• Various heuristics
• Situational awareness

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Situational Analysis and Decision Style

• Urgency of the situation
• Moderate urgency
• Low urgency

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Situational Factors Impact on Patient Safety

• Risk factors in decreasing order of magnitude
• Unfamiliarity with the task x17
• Time shortage
  x11
• Information overload x 6
• Misperception of risk x
  4
• Inadequate checking x 3

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Multiple Steps Error Rates

• The greater the complexity of the procedure the
  higher is the probability of error
• Rates are set at a P value of 0.05 percent
• 1 step results in 5 percent chance of error
• 5 steps in 33 chance
• 25 steps in 72 chance
• 50 steps in 92 chance

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Case OneCogans Syndrome

• Rare form of vasculitis
• Mimics allergic symptoms
• Results in hearing loss

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Case One Take Home Points

• What are the important take home points from case
  one?

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Case Two Botulism

• System pressures unscheduled office visit
• Fall back on common diagnosis
• Diagnosis of viral pharyngitis

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Case Two Take Home Points

• What are the important take home points from
  case two?

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Case ThreePneumothorax

• 64 year old male
• Shortness of breath COPD
• Diagnosis of pneumothorax

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Case Three Take Home Points

• What are the important take home points from case
  three?

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Case FourAmyloidosis

• 70- year old male with congestive heart failure
• Multiple symptoms all attributed to heart failure
• Purpura
• Amyloidosis

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Case Four Take Home Points

• What are the important take home points from case
  four?

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Case FiveOsteoporosis

• Breast cancer in the past
• Arm pain
• Bone scan shows no metastasis
• Radiotherapy for pain relief
• Back pain
• Again radiotherapy
• Diagnosis degenerative weakening, or
  osteoporosis

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Case Five Take Home Points

• What are the important take home points from case
  five?

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Case SixType 1DM, Non-compliant

• 36-year old African American female with type 1
  diabetes mellitus
• Pattern of extra insulin before coming to the
  office
• Local ER twice recently for hypoglycemia
• Sent to her primary care physician for
  supervision
• Next ER visit shows creatinine of 2.0 mg/dl

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Case Six Take Home Points

• What are the important take home points from case
  six?

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Organizational Stressors and Human Cognition

• Clinical decisions embedded in
• Organizational stressors
• Psychological interaction
• Human cognition

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If To Err Is Human, How ?

• Ability to adjust to situations that go awry
• Individual variability as defense against systems
  errors

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Patient Safety Interactive Learning Community
(PSILC)

• Program Information Updates
• All Seven Modules
• Refresher Exercises
• Email Discussion Groups

• http//www.acponline.org/ptsafety

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Refresher Exercises

• http//www.acponline.org/ptsafety