Risk management issues in postmenopausal health care

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Risk management issues inpostmenopausal health
care

• Aboubakr elnashar
• Benha University Hospital

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Outline

• Risk management (RM)
• Postmenopausal health care (PMHC)
• RM in PMHC
• What could go wrong in PMHC?
• How can risk be reduced?

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Risk Management (RM)
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• Back ground
• Preventable errors in medical practice are
  frequent Much patient harm
• Cost a tremendous amount of money.
• How
• To protect doctors hospitals from claims?
• To improve quality of care?

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• Managing Risk
• Definition
• A process for improving the safety quality of
  care through reporting, analyzing
• learning from adverse incidents involving
  patients.

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Misconceptions I. RM is not primarily about
avoiding or mitigating claims It is a tool for
improving the quality of care. II. RM is not
simply the reporting of patient safety incidents.
Incident reporting is on the reactive side of
RM. Minimizing the occurrence of patient safety
incidents is the Proactive side, E.g. instead of
fire fighting after things have gone wrong, a
scenario training (fire drill) III. RM is not
the business of service managers It is the
business of all stakeholders in the organization,
clinicians non clinicians.
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• Basic Questions
• Risk Identification What could go wrong?
• Risk Analysis What are the chances of going
  wrong and what would be the impact?
• Risk Treatment What can we do to minimize
  chances of happening or mitigate damage when it
  has gone wrong?.
• Risk Control, sharing learning What can we
  learn from things that have gone wrong ?.

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• Application
• At any level of
• an organization
• Hospital, unit, department or
• Process.
• Investigation, Treatment, Surgery

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• Requirements for implementing a departmental RM
  program
• Leadership
• Team

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• RM process
• Risk identification
• Looking at what went wrong
• Analysis of patient safety incidents, including
  near misses Root cause analysis
• Looking at what potentially could go wrong
• Identifying prospective risk Failure Mode
  Effects Analysis (FMEA).

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• Sources
• Risk assessment conducted in all clinical areas
  (wards, clinics, theatre, delivery suite, day
  assessment unit, etc.)
• Incident reporting
• Complaints claims
• Staff consultation workshops, surveys,
  interviews
• Clinical audit
• a quality improvement process to improve patient
  care outcomes through
• systematic review of care against explicit
  criteria the implementation of change

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Reporting Each unit should have a list of
reporting incidents (trigger list) 1. Near miss
A potential for harm or error which is
intercepted prior to the completion of the
incident/ event resulting in no harm to
the patient. 2. Incidents Any event that has
caused harm, or has the potential to harm
patient or visitor Any events which involves
malfunction or loss of equipment property or any
event which might lead to a complaint.
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• 3. Adverse events
• An unintended injury or complication, which
  results in disability, death or prolonged
  hospital stay and caused by health care
  management rather than the disease process.

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4. Sentinel events A subset of adverse events,
occurs independently of a patient
condition. Reflects deficiency in hospital
system One who watches or guards
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• II. Risk analysis evaluation
• Risk score
• By multiplying the severity of the incident by
  the likelihood of its occurrence.
• All reported cases should be entered into a
  database permit examination and to generate
  audits of recurring topics.
• Confidentiality
• No blame culture based feed back to clinician.
• The review group may introduce a filtering
  mechanism in order to reduce the number of cases
  for detailed appraisal
• Assessment of cases is often restricted to
  whether or not the outcome was substandard, and
  whether or not contributed to the adverse out
  come.

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• III. Risk treatment
• Action planes
• Elimination
• Substitution
• Reduction or
• Acceptance of the risk
• Depend on
• Risk rating
• Resource implications.
• Culture.

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• IV. Risk Control, sharing learning
• What can we learn from things that have gone
  wrong ?

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Postmenopausal health care (PMHC)
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• Management of menopause symptoms or HRT
• Preventive therapeutic management of
• osteoporosis, other degenerative conditions,
• postmenopausal bleeding,
• urinary symptoms
• psychological wellbeing.

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• Unintended harm to patients may occur in the
  course of PMHC, and measures to ensure patient
  safety should be actively promoted.
• The magnitude of threat to patient safety varies
  with the setting.

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• PMHC is delivered in a variety of settings
• General or special-interest clinics in general
  practice,
• Community menopause clinics,
• Hospital- based menopause clinics
• General outpatient clinics.
• Each centre should conduct its own risk
  assessment have measures in place to contain
  risk.

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RM in PMHC
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• What could go wrong in PMHC?
• Patient safety incidents near misses may occur
  as a result of
• 1. Error in diagnosis
• 2. Error in treatment
• 3. Failure of communication.

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• 1. Error in diagnosis
• Inadequate medical history
• Full history before prescribing HRT e.g.
• Symptoms may direct the physician to the
  climacteric, but the possibility of an
  undiagnosed endocrine, CV, mental health or other
  problem should be considered

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• b. Misinterpretation of symptoms
• E.g.
• VMS tiredness may be due to thyroid over - or
  under-activity, respectively.
• Mental illness may be misdiagnosed as a
  perimenopausal phenomenon.
• Self completed climacteric questionnaire
  facilitate history taking within time constraints,

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• C. Failure to examine the patient.
• E.g. Routine examination of the breasts.
• Controversy.
• Breast examination should be performed only where
  there is a clinical indication
• (The Committee on Safety of Medicines)
• Many clinicians feel it is safer to perform a
  routine examination of the breasts.
• Breasts are not always examined when there is a
  clinical indication delayed diagnosis.

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• 2. Error in treatment
• Failing to screen or treat an at-risk woman
• E.g.
• With an intact uterus E should not given alone
• This principle is not always followed
  endometrial cancer (Rees Purdie, 2006)
• Contraception for the perimenopausal woman is not
  prescribed
• Fertility rate is low,
• Age
• Medical conditions
• The consequences of an unwanted pregnancy are
  profound.

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• b. Inadequate monitoring of long term therapy
• Not all postmenopausal are suitable for
  management in a general primary care facility
• Referral to specialist at the appropriate time
• Diabetes
• Previous breast cancer
• HRT with abnormal bleeding

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• c. Inadequate follow-up arrangements.
• More careful assessment with a pre-existing
• medical condition (Rees Purdie, 2006)
• Refer to breast disease, cardiology,
  rheumatology, haematology urogynaecology

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• 3. Failure of communication
• I. Between doctor patient.
• Consent
• Vital in clinical practice
• Avoiding litigation.
• Involving patients in their care
• Facilitated by the provision of oral written
  information for patients.

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• Discussion
• Risks, benefits alternatives of the intervention
  e.g. HRT
• Documented esp if controversy
• e.g. HRT with history of DVT or Breast ca
• Checklist

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Investigation e.g. cervical smear, mammogram or
US. Ordered Follow up the results Inform the
women
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II. Between doctors particularly when a woman is
transferred from one doctor to another
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II. How can risk be reduced? Patient safety is
enhanced by quality-oriented organization of
menopause services. I. Proactive identification
management of risk Prospectively identifying red
flags II. Incident reporting III. Clinical audit
that assures optimal standards of care. IV. Oral
written information to patients V. Good
practice in relation to patient consent VI. Good
documentation
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• VII. Nominated guidelines Care pathways
• Each unit should have
• The British Menopause Society has published care
  pathways for menopause osteoporosis (Rees
  Purdie, 2006).
• Care should be standardized through EB
  guidelines protocols
• E.g.
• HRT
• Risk assessment at commencement,
• Follow-up visits.
• Advice when there is uncertainty

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• VIII. Education training
• of the staff (Mander Edozien, 1998)
• Quality standards in postmenopausal care (Gray ,
  2007)
• Stick to safe practice
• Guidance from the General Medical Council (GMC,
  2006)
• Medico legal pitfalls in prescribing HRT, 2006
• Safety alerts
• In 2006, an alert on hepatotoxicity associated
  with black cohosh, used to treat menopausal
  symptoms

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Conclusion

• Patient safety incidents near misses may occur
  as a result of
• Error in diagnosis
• Error in treatment
• Failure of communication.
• A proactive approach to RM
• Help reduce errors in diagnosis treatment
• Facilitate communication
• Enhance patient safety.

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