RIH Patient Safety

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RIH Patient Safety

• Melinda Morin, MD
• Chair, Patient Safety Program

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The realities

• 100,000 people die every year in U.S. hospitals
  as the result of medical error
• 1/3 of health care professionals report some
  adverse event to self/family
• We are human - We all make mistakes
• Goal keep our mistakes from reaching the
  patient
• Solution make the health care system safer

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The numbers

• We dont want to believe them
• It doesnt square with personal experience
• No. of practicing physicians 750,000
• No. of preventable deaths/yr 100,00
• Average 30 year career
• Every 7 yrs, each MD will have a preventable
  death, harm 50 100, near miss 1000 pts
• Most mistakes not recognized
• Autopsies with major unsuspected diagnosis 20 -
  40

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Types of errors

• Diagnostic (error/delay in diagnosis, failure to
  employ indicated tests, failure to act on exam
  findings/test results)
• Treatment (medication errors, wrong-side surgery)
• Preventive (failure to provide prophylactic
  treatment)
• Communication failure

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Case 1

• 32 y.o. patient in the ICU is extubated after a
  prolonged ARDS course
• She is breathing comfortably, but has evidence of
  benzodiazepine withdrawal.
• She is given 5 mg of Lorazepam and has a
  respiratory arrest
• It is discovered that she received Rocuronium
  instead - the drug had been sitting at the
  bedside in case she needed to be re-intubated.

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Case 2

• 3 y.o. scheduled for strabismus surgery.
• 2.5 y.o. scheduled for TA
• Similar sounding names
• Family of the 3 y.o. is non-English speaking
• 3 y.o. underwent the TA although tonsils looked
  normal

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Case 3

• 66 y.o. with a history of alcoholism is found
  unresponsive on the street
• Admitted to the drunk tank
• Noted to have hypotension which is dutifully
  documented
• After 4 hours of systolic bps in the 70s
  patient found to have a C5 fracture.

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• 2007 Hospital National Patient Safety Goals
• Goal 1 Improve the accuracy of patient
  identification.
• 1A Use at least two patient identifiers when
  providing care, treatment or services.
• 2 Improve the effectiveness of communication
  among caregiv ers.
• 2A For verbal or telephone orders or f or
  telephonic reporting of critical test results,
  verify the complete
• order or test result by having the person
  receiving the inf ormation record and "readback"
  the
• complete order or test result.
• 2B Standardize a list of abbreviations, acronyms,
  symbols, and dose designations that are not to be
  
• used throughout the organization.
• 2C Measure, assess and, if appropriate, take
  action to improv e the timeliness of reporting,
  and the
• timeliness of receipt by the responsible
  licensed caregiver, of critical test results and
  values.
• 2E Implement a standardized approach to hand off
  communications, including an opportunity to ask
  
• and respond to questions.
• Goal 3 Improve the saf ety of using medications.
  
• 3B Standardize and limit the number of drug
  concentrations used by the organization.
• 3C Identify and, at a minimum, annually review a
  list of lookalike/soundalike drugs used by the
• organization, and take action to prevent errors
  involving the interchange of these drugs.
• 3D Label all medications, medication containers
  (f or example, syringes, medicine cups, basins),
  or other
• solutions on and off the sterile field.

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Bar coding/Patient ID
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Use of checklist/time-out process
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Do Not Use Abbreviations
Dig Digitalis/digoxin Digoxin DTO Deodorized
Tincture of Opium Deodorized Tincture of Opium
DTO Diluted Tincture of Opium Pediatric Morphine
Oral Solution 0.4 mg/ml Gr. Grain Use the metric
system IU international unit Lack of leading
zero (.X mg) Always use a zero before a decimal
point (0.X mg) MS morphine sulfate morphine
MSO4 morphine sulfate morphine MgSO4 magnesium
sulfate magnesium sulfate Nitro Nitroglycerin
Nitroglycerin or Nitroprusside Qd or QD daily
daily QID or qid Four times daily 4XD Qod or
QOD every other day Trailing zero (X.0 mg) Never
write a zero by itself or after a decimal point
(X mg) U units ? Dram Use the metric system ?
Minim Use the metric system µg micrograms
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Proper Hand Hygiene
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80 hour work week for Residents/Fellows
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Your involvement in Creating a Culture of Safety

• Physicians have not been part of the organization
• No other industry allows individuals to ignore
  rules as physicians do
• Goal is to seek a just culture, not a blame-free
  one

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Overcoming physician skepticism

• We dont believe the numbers
• The tyranny of small numbers
• Distrust of the transforming concept
• Unwilling to give up the compact
• Fear

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The transforming concept

• Vague and complicated
• Goes against everything we were taught
• Smacks of irresponsibility
• Offends our sense of free agency

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Unwilling to give up The Compact

• I am a physician
• Who are you to tell me how to practice
• I dont need checklists
• Practicing the art of medicine