Patient Safety: How Can You Prevent Medical Errors

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Patient Safety How Can You Prevent Medical Errors

• Arpana R. Vidyarthi, MD
• Assistant Professor of Medicine
• Division of Hospital Medicine
• Director, Patient Safety and Quality Innovations,
  GME

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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 Progress Over Half a Century
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The Swiss Cheese Model of Major Accidents
Errors
Human Glitch
Patient Harm
James Reason, Human Error
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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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Cure to this epidemic?

• Scientific breakthrough?
• Think outside of our box

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How to Improve Safety?

• Standardizes the process!
• High reliability organizations (HRO theory)
• Maintain a powerful and uniform culture of safety
  
• Use optimal structures procedures
• Conduct thorough organizational learning safety
  management
• Provide intensive and continuing training of
  individuals and teams

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Improving Communication

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

So 1 order moo-shoo, fried riceand what kind of
milk?
Can I get some moo shoo pork, fried riceand milk?
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Handoffs and Sign-outs
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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
Call Resident 5 for information 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 self Poor Edith, she has
  suffered a change of mental status

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Handoffs and Sign-outs

• Decreased duty hours have increased handoffs
• UCSF Medicine Service
• 15 handoffs per patient for a 5 day LOS
• 300 handoffs per month for each intern

UCSF Medical Center 4000 sign-outs daily, 1.5
million a year
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Discontinuity and Patient Harm

• Evaluating the factors associated with
  preventable adverse events in the hospital
• 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 Sign-Outs?

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

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

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

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Verbal Communication Best Practice

• What
• Administrative Data
• Name, location
• Problem list
• Major problems only
• To Do List
• Specific tasks in if-then statements
• Read-back all to-do list items
• Nuance
• Information that cant be conveyed in writing
• Is the patient sick?
• If the treatment plan is in flux

• Where
• Same place each time
• Well-lit place
• No distractions
• Confidential (HIPAA compliant)

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First Do No Harm

• Safety of patients is the priority of healthcare
• .but we could be doing a better job!

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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
• Think about your communication
• Colleagues.
• Nurses
• Handoff patients with care

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