Medical Education Institutions: Developing a Culture of Patient Safety

1
Medical Education Institutions Developing a
Culture of Patient Safety

• Richard Terry, DO, FACOFP, Director
• Wilson Family Practice Residency Program
• Paul Decker, Risk Management Consultant
• Medical Liability Mutual Insurance Company

2
Objectives

• Understand the perception of medical errors by
  residents in teaching institutions.
• Identify key risk areas in patient care where
  resident-related medical errors commonly occur.

3
Objectives

• Describe risk management strategies to help
  prevent medical errors, mitigate liability
  exposure, and improve patient care.
• Recognize that clinicians involved in medical
  errors may experience personal distress.
• Realize the importance of developing a culture of
  safety in teaching institutions to address and
  reduce medical errors.

4
Background Study 2005

• Perceptions of Medical Errors by Internal
• Medicine Residents Development and
• Validation of a New Scale. The School of
• Medicine, University of Alabama, and Florida
• State University, College of Medicine.

5
Study findings Residents Perceptions

• Residents theorized that the majority of
• medical errors occurring in the U.S. were
• Attributable to allied health professionals.
• Related to patient issues. For example, atypical
  presentations, unintended outcomes and complex
  medical conditions/comorbidities
• The result of financial incentives such as cost
  containment or managed care reimbursement
  structures.

6
Study Conclusion

• Residents perceive additional education in
  medical error reduction strategies (Risk
  Management) is needed by allied health
  professionals (e.g., nurses, physicians
  assistants and medical technologists) but not
  physicians.

7
Change Needed in Academic Culture

• Empirical Evidence shows that physicians are the
  primary source of medical errors and medical
  malpractice losses. Therefore, there needs to be
  a change in how residents perceive medical
  errors.
• Faculty advisors and teaching institutions need
  to assist in correcting these misperceptions.

8
Definition of Malpractice

• Professional negligence in which a physician,
  surgeon, or dentist deviates from the approved
  and accepted standards of practice within a given
  specialty, thereby causing an injury or damage to
  a patient.

9
Definition of Healthcare Risk Management

• An administrative activity aimed at preventing
  the loss of healthcare provider resources
  resulting from actual or alleged accidents,
  neglect, or incompetence.

10
Definition of Medical Error

• The Institute of Medicine (IOM) defines medical
  error as the failure to complete a planned
  action as intended or the use of a wrong plan to
  achieve an aim.

11
Patient Risk Issues in Medical Education Programs

• Residents provide the majority of inpatient
  physician care in US teaching hospitals.
• Residents care for large populations of patients
  in academic settings.

12
Patient Risk Issues in Medical Education Programs

• University medical centers often care for the
  most difficult cases.
• University medical centers are frequently located
  in underprivileged areas where the patient base
  tends to lack preventive healthcare.

13

• Common Patient Care Issues in Residency-Based
  Programs and their Remedies

14
Medical Record Documentation

• Sound documentation practices will provide a
  solid basis for defending good care in a medical
  malpractice or general liability case.

15
Medical Record Documentation

• Failure to document adequately can lead to
  allegations of substandard care.
• Solution Consider using structured comprehensive
  notes such as the S.O.A.P. format (subjective,
  objective, assessment and plan of management).

16
Medical Record Documentation

• Poor documentation compromises the defense of a
  professional liability lawsuit.
• Solution Residents should receive regular and
  timely feedback from attending physicians about
  the quality of their documentation.

17
Medical Record Documentation

• Electronic medical records (EMRs) have the
  potential to enhance patient care and reduce
  medical errors. However, there are documentation
  considerations that need to be addressed when
  utilizing an EMR. For example, generic templates
  and checklists can be less comprehensive than
  traditional notes.

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Medical Record Documentation

• Solution Complete all pre-determined fields on
  EMR templates and checklists. Add narratives
  where appropriate. Your record documentation
  should describe your thought and decision making
  processes in determining the diagnosis and
  treatment plan.

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Medical Record Documentation

• Your documented rationale for the treatment
  plan should allow for another practitioner to
  pick up where you left off in patient
  transfers/hand-offs.
• Memorialize your conversations with attendings
  and consultants in your patient progress notes.

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Medical Record Documentation

• The sequencing of patient related events can be
  critical when evaluating care provided. Date,
  time and sign all medical records entries.
• Do not alter the medical record in any way. Be
  honest and truthful in your record keeping.

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Medical Record Documentation

• Limit adding late addendums to the record. If you
  do write an addendum, be sure to document the
  correct date and time of the medical record
  entry.
• Write legibly, do not correct or alter another's
  notes, do not leave spaces, and follow your
  facilitys approved abbreviation list.
• Do not keep personal notes on patients as these
  records may be discoverable.

22
Failure to Consult with the Attending Physician
in Complex Cases

• Solution Review all cases with the attending
  physician.
• Note Senior residents in many programs are not
  required to review all cases with their attending
  physicians aside from Medicare and Medicaid
  patients.
• This practice can lead to a substantial gap in
  peer review, inadequate care and treatment, and
  can facilitate the occurrence of medical errors.

23
Failure to Consult with the Attending Physician
in Complex Cases

• All significant decisions made by residents
  (e.g., admitting, discharging, changes in
  medications) should be made with attending
  physician oversight.
• Remember to document these conversations/consultat
  ions.

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Failure to Consult with the Attending Physician
in Complex Cases

• Use accepted clinical guidelines.
• E.g., National Guideline Clearinghouse (NGC)
  provides over 700 evidence-based guidelines to
  assist clinicians identify and better understand
  evidence-based treatment strategies.

25
Lack of Accountability or Inadequate Follow-up
Care

• Residents sometimes perceive that they are not
  accountable to clinic patients, as they are not
  really their patients.
• They often assume an attending or colleague who
  last saw the patient is responsible for the
  continued care of the patient.

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Lack of Accountability or Inadequate Follow-up
Care

• Solution Residents need to buy into the
  ownership of each patient they treat and ensure
  proper follow-up care is arranged, (e.g., ordered
  test results).
• Memorialize in the record any conversation with
  the attending as to who will follow-up on
  individual patient issues.

27
Failure to Follow-up on Abnormal Tests/Studies

• Occasionally, significant information such as
  abnormal lab reports or positive radiographic
  findings are overlooked, and proper follow up
  care is not rendered.

28
Failure to Follow-up on Abnormal Tests/Studies

• Solution Results of tests/studies must be
  reviewed by a provider, preferably by the
  ordering physician.
• Residents should arrange patient contact or a
  follow-up visit, preferably with themselves, for
  all patients when diagnostic tests/studies are
  ordered.

29
Failure to Admit to or Report Medical Errors

• Providers are often reluctant to report errors or
  admit to their own mistakes, fearing punitive
  action.
• Solution The academic setting should encourage
  the discussion of medical errors/near misses in a
  blame-free environment.

30
Failure to Admit to or Report Medical Errors

• Errors and near misses need to be discussed in
  order to prevent them from reoccurring.
• Contact the Risk Management Department when an
  error occurs so that appropriate action can take
  place to disclose the error to the patient.

31
Failure to Admit to or Report Medical Errors

• A true culture of safety is one in which every
  member of the healthcare team feels free to voice
  opinions and concerns regarding a patients plan
  of care, and in which the fear commonly
  associated with reporting errors or disagreeing
  with those in positions of authority is
  eliminated.

32
Prescribing Errors or Misunderstood Verbal Orders

• Paper-based prescribing errors are among the most
  common medical errors and can be the most
  serious.
• The residents lack of pharmaceutical knowledge,
  poor penmanship and carelessness can be
  contributing factors.

33
Prescribing Errors or Misunderstood Verbal Orders

• Solution EMR systems and other new software
  tools show promise in reducing medication errors.
  
• Residents must check the dose and potential
  interactions of any drug they prescribe, and know
  its indications.

34
Prescribing Errors or Misunderstood Verbal Orders

• Residents who are on call and in the hospital,
  should see a patient if there is a change in
  their status and new medications or dosages need
  to be ordered.
• Verbal orders by their very nature should be used
  sparingly. In addition, residents must ask the
  nurse to read back a dictated order, confirming
  that the order is correct.

35
Training in Procedures

• There is a need for standardized training so that
  residents are taught to perform procedures
  correctly and for appropriate indications.
• The see one, do one, teach one philosophy does
  not guarantee proficiency.

36
Training in Procedures

• Solution Formal training programs and refresher
  courses are useful in teaching certain
  procedures.
• Teaching tools, such as simulation models,
  workshops and formal training sessions, can help
  improve competence in performing procedures.

37
Disruptive Behavior

• Disruptive clinician behavior is conduct that
• interferes with the provision of quality patient
  care,
• including
• sexual harassment,
• making or threatening reprisals for reporting
  disruptive behavior,
• shouting or using vulgar or profane language,
• and acting in an abusive way towards patients or
  staff (i.e., physical assault, intimidating
  behavior, and refusal to cooperate with other
  staff members).

38
Disruptive Behavior

• Solution Each resident should be supplied with a
  copy of the facilitys zero tolerance for
  aberrant behavior policy and this policy must be
  enforced.
• When necessary, residents as well as staff should
  be counseled, and if appropriate, receive
  professional assistance (i.e., anger management
  training.)
• Individuals who develop patterns of abusive
  behavior towards patients, other physicians, and
  staff must be held accountable for their actions.

39
Resident Personal Distress

• Committing medical errors can have a significant
  impact on clinicians, leading to feeling of
  distress, guilt, shame, and depression.
• Most physician residency programs lack formal
  programs to support resident physicians in coping
  with the distress of committing serious medical
  errors.

40
Resident Personal Distress

• Physicians can suffer from post-traumatic stress
  disorders following significant medical errors.
• Support programs designed to address these
  personal distress issues, such as therapeutic
  discussion groups, need to be implemented in
  teaching institutions.

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MLMIC Dateline Articles

• http//www.mlmic.com/portal/Dateline.aspx

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Conclusion

• Physician residency programs offer the medical
  community a unique opportunity to fine tune how
  medicine is practiced now and in the future.
  Post-graduate medical education programs that
  focus on the reduction or elimination of medical
  errors should be at the forefront of cultural
  change.

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