Patient Safety on Teaching Rounds Modulettes Faculty Development

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Patient Safety on Teaching Rounds (Modulettes)
Faculty Development

• John Gosbee, MD, MS
• VA National Center for Patient Safety
• John.Gosbee_at_med.va.gov www.patientsafety.gov

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Location in our VA NCPS Curriculum Toolkit

• Content
• Patient Safety Introduction
• Human Factors Engineering
• Etc

• Instructor Preparation
• Swift and Long Term Trust
• Selling the Curriculum
• Etc

• Alternative Education Formats
• Pt Safety Case Conference (MM)
• Pt Safety on Rounds (Modulettes)
• One-month Elective
• Etc

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Objectives

• Understand the formats for using modulettes
  during work rounds that have shown promise
• Understand content of example modulettes
• Oxygen-Medical Air wall outlet confusion
• MR safety of sand bags
• AMBU bag
• Defibrillator-Pacemaker
• Develop tactics to find examples/cases/demos

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Overview of formats that have shown promise

• Approach 1
• Watch and listen for safety issues during rounds
• Pick one at end and discuss for 5-10 min
• Relevant, but incomplete
• Approach 2
• Have 5-10 modulettes in your back pocket
• When a patient is using it or involved with it,
  pounce!
• Less relevant, but more complete

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Solving the conflict issue.
Best
It should look like this, but we know it often
doesnt
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Example 2 MR safety of sand bags

• MR is always on (25K to 500K to shut off)
• Magnetic field is always invisible

Is this sand bag a problem?
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MR safety of sand bags

• Not all metallic appearing stuff is magnetic, and
  vice versa
• Some sand bags have iron in them
• From discomfort to death
• American College of Radiology
• MR safety guidelines
• Emanuel Kanal, MD collects hundreds of stories

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Example 3 AMBU bag attachment confusion
leading to delayed use
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Example 4 Defibrillator-Pacemaker

• Recently designed to be attached with pads
  leads
• Hands-off design

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Defibrillator-Pacemaker

• Now used clinically for
• Temporary external pacing
• Attached and left off, just in case
• If the curtain is closed, what happens?
• Who left that crash cart on?
• Its time for the 3/day 200J testing

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What Can Be Seen Here?
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Avoidable Confusion is Everywhere
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Where to find examples along with patient safety
analysis

• Your Patient Safety Manager!!!
• VA National Center for Patient Safety web site
• Some examples can be used as is
• Web MM
• Many cases pretty translatable and usable
• Patient safety series in Annals and NEJM
• Longer articles more clinical
• In general, not as translatable or system focused

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References

• AHRQs Web MM site. http//www.webmm.ahrq.gov/
• Gosbee JW, DeRosier J. MR Hazard Summary. VA
  NCPS Web Site. http//www.patientsafety.gov/alerts
  /MRI.doc
• National Center for Patient Safety Newsletter and
  Case Examples. http//www.patientsafety.gov/tips.h
  tml
• Thomas AN, Hurst W, Saha B. Interchangeable
  oxygen and air connectors. Anaesthesia. 2001
  Dec56(12)1205-6. http//www.ncbi.nlm.nih.gov/
• Waite A, Macartney I. Air-oxygen flowmeter
  confusion. Anaesthesia. 2003 Feb58(2)194-5.
  http//www.ncbi.nlm.nih.gov/

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See Journal Club Module for Even More

• Annals of Internal Medicine - Quality Grand
  Rounds. http//www.annals.org/cgi/content/full/1
  36/11/850
• Journal of Academic Emergency Medicine -
  'Profiles in Patient Safety' http//www.aemj.org/c
  gi/reprint/9/4/324.pdf
• Institute for Safe Medication Practice Medication
  Safety Alert!All access www.ismp.orgVA access
  only http//vaww.pbm.med.va.gov/pbm/menu.asp
• FDA Medical Device Adverse Event
  Database(http//www.accessdata.fda.gov/scripts/cd
  rh/cfdocs/cfMAUDE/search.CFM)
• Quality and Safety in Healthcarehttp//www.jcrinc
  .com/subscribers/journal.asp?durki32