Intern Survival Series Lecture #4 Preventing Medical Error As an Intern Shaping the Future of Healthcare | www.thewrightcenter.org
Objectives • After participating in this lecture, you should be able to: – Identify important steps in the anatomy of medical errors – Be able to identify the important places where you as an intern can decrease medical error – Identify the importance of an appropriate medical reconciliation and how to avoid pitfalls – Identify the importance of comprehensive signout and how to avoid pitfalls Shaping the Future of Healthcare | www.thewrightcenter.org
A Brief Note • This lecture series is not meant to be all inclusive or totally comprehensive to all of medicine • It is not meant to supersede clinical judgment • It is not meant to replace daily reading or bedside teaching • It is meant to act as a starting point for which to grow from as new primary care physicians • It is a tool to help you survive the your new job Shaping the Future of Healthcare | www.thewrightcenter.org
Warning Tags Precipitated by Human Error Shaping the Future of Healthcare | www.thewrightcenter.org
Warning Tags Precipitated by Human Error Shaping the Future of Healthcare | www.thewrightcenter.org
Warning Tags Precipitated by Human Error Shaping the Future of Healthcare | www.thewrightcenter.org
Warning Tags Precipitated by Human Error WARNING: Never use a lit match or open flame to check fuel level Shaping the Future of Healthcare | www.thewrightcenter.org
Warning Tags Precipitated by Human Error Shaping the Future of Healthcare | www.thewrightcenter.org
Warning Tags Precipitated by Human Error Shaping the Future of Healthcare | www.thewrightcenter.org
Medical Warning Tags • Do not give patient’s organs they are not suppose to receive Shaping the Future of Healthcare | www.thewrightcenter.org
Medical Warning Tags • Do not give pregnant women medications that can cause birth defects or abortion. Shaping the Future of Healthcare | www.thewrightcenter.org
Medical Warning Tags • Do not give colleagues wrong or incomplete information of patients they will be caring for • Do not continue patient medications that they are not prescribed • Do not start medications that are not indicated Shaping the Future of Healthcare | www.thewrightcenter.org
Wrong-Patient Medication Errors Examined by the Pennsylvania Patient Safety Authority • June 3 rd , 2o13 • Over 800 wrong-patient medication errors were reported to the Pennsylvania Patient Safety Authority in a six-month period • Insulin, heparin, vancomycin were the three most common medications involved • 30% of the errors were associated with high- alert medications Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Medical Error • Occurs when: – a health-care provider chooses an inappropriate method of care – improperly executes an appropriate method of care. • Medical errors are often described as human errors in healthcare Shaping the Future of Healthcare | www.thewrightcenter.org
To Err is Human • Landmark Report • Released in 1999 by the Institute of Medicine (IOM) • revealed that between 44,000 and 98,000 people died each year in US hospitals due to medical errors. Shaping the Future of Healthcare | www.thewrightcenter.org
To Err is Human • Astounding numbers • Equivalent of three fully loaded jumbo jets crashing and killing everyone onboard every other day • Report called for a swift reduction of medical errors in the United States. Shaping the Future of Healthcare | www.thewrightcenter.org
Where are we now • After 14 years – Medical Errors are still very high – Numbers are still under reported Shaping the Future of Healthcare | www.thewrightcenter.org
Sentinel Events • Defined by The Joint Commission (TJC) • “any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness” Shaping the Future of Healthcare | www.thewrightcenter.org
Sentinel Events • Reporting – Participation is necessary by the leadership of TJC & the systems under review (WCGME). – Causal factors are analyzed • focusing on systems and processes • not individual performance Shaping the Future of Healthcare | www.thewrightcenter.org
Sentinel Events • Actions: – May modify the organization's current accreditation status – Outcomes to system • appropriate "measure of success” • require follow-up survey within six months. – A healthcare facility that fails to complete a root cause analysis of the sentinel event and action plan within the time frame can be placed on "Accreditation Watch" by the Joint Commission • can be publicly disclosed Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Understanding Why Harmful Errors Occur • ~95% percent of medical harm involves conscientious, competent individuals involved in circumstances that lead to a catastrophic result • These can be broken down into several factors that impact human performance and increase risk for error Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Resident Medical Error Shaping the Future of Healthcare | www.thewrightcenter.org
Factors Contributing to Harmful Errors can be thought of like Renal Disease – Factors in play before the harmful action takes place (pre-renal) • Ex: – Lack of sleep affecting judgment – Work fatigue from going over duty hours – Factors that directly disrupt decision making (infra-renal) • Ex: – Lack of knowledge about particular disease state leads to Rx wrong or contraindicated medication – not reading up on patient’s ailment or keeping up to date with current guidelines leads to an inappropriate action or inaction – Factors that directly affect decision execution (post-renal) • Ex: – Not following up on a correctly ordered test Shaping the Future of Healthcare | www.thewrightcenter.org
Preventing Unsafe Acts in Healthcare • In General: – A “systems approach” to addressing medical error is taken • Systems enact defenses to prevent accidents • Member include: – Institutions » WCGME, GCMC, VAMC, CHS – Organizations » ACP, ACOI, AMA, AOA – Teams » A,B,C, D, H – Technical » EHR, Lab results, imaging reports Shaping the Future of Healthcare | www.thewrightcenter.org
Preventing Unsafe Acts in Healthcare Focus is concentrated on conditions under which individual providers and care teams work – Defenses are designed into the workflow to avert errors – Focus is to minimize the conditions that lend to errors – Mechanisms are placed to lessen the blow of unsafe acts that may inevitably occur – In spite of this, errors still occur Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
Shaping the Future of Healthcare | www.thewrightcenter.org
How Can You Decrease Medical Error as an Intern? • Comprehensive Medical Reconciliation – Transition of care is the most dangerous time for a patient in any given system – Getting medications correct is easy when it is easy, and very hard when it is not • Sign out – Effective, comprehensive sign out is pinnacle to providing excellent patient care – Accurate patient information is crucial Shaping the Future of Healthcare | www.thewrightcenter.org
Medication Reconciliation • The process of comparing a patient's medication orders to all of the medications that the patient has been taking. • Done to avoid – Omissions – Duplications – Dosing errors – Drug interactions • Shaping the Future of Healthcare | www.thewrightcenter.org
Medication Reconciliation • It should be done at every transition of care in which new medications are ordered or existing orders are rewritten • Transitions in care include changes in setting, service, practitioner or level of care. – OP Medical Home to IP Hospital – IP to Rehab/SNF – Rehab/SNF to OP Medical Home Shaping the Future of Healthcare | www.thewrightcenter.org
Medication Reconciliation This process comprises five steps: 1) develop a list of current medications 2) develop a list of medications to be prescribed 3) compare the medications on the two lists 4) make clinical decisions based on the comparison 5) communicate the new list to appropriate caregivers and to the patient Shaping the Future of Healthcare | www.thewrightcenter.org
KNOW YOUR SYSTEM Shaping the Future of Healthcare | www.thewrightcenter.org
Example of a Good Sign out Shaping the Future of Healthcare | www.thewrightcenter.org
Example of a Not So Good Signout Update? ???? ???? ???? ???? Shaping the Future of Healthcare | www.thewrightcenter.org
Recommend
More recommend
