Patient Safety: How You Can Prevent Medical Errors

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Patient Safety How You Can Prevent Medical
Errors

• Sumant Ranji, MD
• Assistant Professor of Medicine
• Associate Program Director, Internal Medicine
  Residency Program

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Why Are You Here?

• my time in the developing world led me to
• the scientific exchange that I experienced in
  the lab
• UCSFs reputation

Help People---Stomp Out Disease
First Do No Harm
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The IOM Report December, 1999
Exceeds those who die from highway accidents,
breast cancer, and AIDS
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Medical CareThen and Now
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First Do No Harm

• Safety of patients is our priority
• .and we could be doing a better job!

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The Swiss Cheese Model of Major Accidents
Errors
Human Glitch
Flawed Systems
Patient Harm
James Reason, Human Error
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Individual errors are common and expected

• Slips
• Errors involving semi-automatic routines daily
  activities
• exacerbated fatigue, competing tasks

• Mistakes
• Errors in interpretation, misapplication of
  cognitive rules
• more likely in new or unusual situations

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What Type of Human Glitches Cause Harm?
JCAHO Sentinel Event Statistics, 2004
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JCAHO Sentinel Event Statistics, 2004
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JCAHO Sentinel Event Statistics, 2004
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So What Can You Do About It?
Its Not Rocket Science

• Use Communication Tools
• Be Conscientious of Signouts
• If you see something wrong, tell someone

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Communication Tools
So 1 order moo-shoo, fried riceand what kind of
milk?

• Read back for all verbal orders
• Standardization for order sets
• OR Time-Outs
• Involve nursing

Can I have an order of moo-shoo pork, fried rice,
and milk?
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SignoutsPart of Your Everyday Life

• UCSF Medical Center
• 4000 signouts daily
• 1.5 Million yearly

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Case Presentation Edith presents with SOB
TimeLine
7AM
6AM
5AM
4AM
3AM
2AM
1AM
12AM
8AM
Shortness of Breath Sent for CXR
Labs Admit Settled on ward
Edith in ED ED Resident 1
Shift Change ED Resident 2
Night Float Resident
Medicine ward Medicine Resident
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Day 1
TimeLine
2 PM
10AM
6AM
2AM
10PM
6PM
2PM
10AM
6PM
Decompen-sates Edith in ICU Edith in
ICU Edith Stable Edith Stable
Transfer to ICU On Call Medicine Resident 5
Resident 5 goes to clinic Cross coverage Resident
Resident 5 returns
Resident 5 goes home Day Float Resident
Day Float goes home On call intern
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Day 2
TimeLine
12 PM
8AM
6AM
2AM
10PM
6PM
2PM
10PM
4PM
Edith in ICU Shortness of Breath/
Intubated Intubated Stable Extubated
On Call intern sign out Intern Night Float
Resident 5 Returns
Resident 5 continues
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The first 48 hours of Ediths stay.
Total Residents in Charge of Care 9 Total
Sign-outs 10

• Resident 5 Do you remember us Edith, we are
  the doctors taking care of you?
• Edith Uh.no?
• Resident 5 to intern She seems altered. Lets
  get a stat head CT.

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Discontinuity and Patient Harm

• Most significant risk for an adverse event
• cross-covering MD

Petersen, L. A. et. al. Ann Intern Med
1994121866-872
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What Can You Do To Diminish Harm at Signouts?

• Take it seriously!
• Use standardized tools

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Communication Channels
www.agilemodeling.com/essays/communication.htm
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What Can You Do To Diminish Harm at Signouts?

• Take it seriously!
• Use standardized tools
• Verbally sign out
• Role model

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Think About What You Would Want To Know

• Who
• What
• Administrative Data
• Problem list
• To Do List
• Nuance
• Where

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The Swiss Cheese Model of Major Accidents
Errors
Human Glitch
Flawed Systems
Patient Harm
James Reason, Human Error
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How you can help fix the system

• Report problems
• Incident reports/near miss reports
• Let us know arpana_at_medicine.ucsf.edu,
  sumantr_at_medicine.ucsf.edu
• Join a QI committee
• Dont fear the RCA
• Tell your chief residents!

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But most importantly

• If youre in an unfamiliar situation
• ASK FOR HELP

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Medical CareThen and Now
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Building Safer Systems
Think of your doctors and nurses as actors in a
grand play. Sure, the play is different when
King Lear is played by Sir Laurence Olivier or
Robin Williams. But Lear dies in both stagings.
If we want the patient to live, we must change
the script!
Internal Bleeding, Wachter and Shojania
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You Can Change The Script

• Prioritize safety in your everyday work
• Use communication tools
• Signout patients with care
• Report problems you see
• Ask for help!

First Do No Harm
Help People---Stomp Out Disease
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THANKS