ResidentEducatorDevelopment

The RED ProgramA Residents-as-Teachers Curriculum

Developed by Heather A. Thompson, MD

The RED Program

• Team Leadership• How to Teach at the Bedside• The Microskills Model: Teaching during

Oral Presentations• How to Teach EBM• The Ten Minute Talk• Effective Feedback• Professionalism• Patient Safety and Medical Errors

Patient Safety and Medical Errors

Medical Errors: Public Interest

• Institute of Medicine Report (1998)• Errors are responsible for preventable

injury in as many as 1 out of 25 patients• Errors estimated to cost more than $5

million per year in a large teaching hospital– Total annual cost = $17 to $29 billion

• Estimated 44,000-98,000 people die each year from medical errors– more than MVAs, Breast ca, and AIDS– 8th leading cause of death

Medical Errors: Media

Why include this in a Residents-as-Teachers Program?

• Residents are in a unique position to identify systems errors at a teaching hospital

• Residents can teach interns and students how to approach medical errors

• Work hours rules, handoffs (night float, day float) make reduction of error and reliable systems of care all the more important

• To reduce the culture of “blame and shame”, we need to start early on in medical training

ACP Patient Safety Curriculum

“Patient Safety—The Other Side of the Quality Equation” Cristel Mottur-Pilson, PhD, Principal Investigator

• Systems• Cognitive Capacity• Communication• Medication Errors• The Role of Patients• The Role of Electronics• Idealized Office Design

Objectives

• Define “system”• Recognize the role of systems in

both allowing and preventing medical errors

• List several steps that residents can take to prevent medical errors within these systems: “take home points”

The Concept of Patient Safety

• Dates back to the time of the Hippocratic Oath: “I will prescribe a regimen for the good of my patients according to my ability and my judgment and NEVER DO HARM TO ANYONE…”

The Concept of Patient Safety

• Patient Safety is defined as freedom from injury (Kohn), or the absence of medical errors or adverse events

• The IOM defines error:“An error is defined as the failure of a planned action to be completed as intended (i.e. an error of execution) or the use of a wrong plan to achieve an aim (i.e. error of planning).”

The Concept of Patient Safety

• Adverse Event (AE): An injury resulting from medical intervention, not due to the patient’s underlying condition

• Sentinel event: a “near miss” in which an adverse event did not occur, but alerts people to the possibility of a future event

What is a system?

• A system is any collection of components and the relations between them, whether the components are human or not, when the components have been brought together for a well-defined goal or purpose.

--Moray

What is a system?

• Berwick’s law: Every system is perfectly designed to produce exactly the results it produces.

• To change the output or the “error rate” of the system, we must change the processes within the system, not just fire the individual most closely tied to the event.

What is a system?

• An error that results in an adverse event usually occurs as a result of numerous breakdowns or “holes”, each at different points in the system.

• An error or a near-miss is an opportunity to step back and analyze the system.

Systems create “latent” errors

• Firing the last person: No help

James Reason.BMJ (2000) 320:768-70

View Video Clip

Resident and student discussing erroneous report of

blood culture result

System Performance Improvement

• In general, all of our efforts are focused on blaming a single person for an isolated incident (such as the blood culture result). This is wrong.

• Instead, we should focus on analyzing the system and identifying areas for improvement.

• Next: Cased based learning

Case one: Ordering a Scan

• One of your patients with chronic renal failure is in the ER complaining of abdominal pain.

• A CT of the abdomen is ordered. It is written on the form: “CT abd w/o contrast.” Diagnosis: “abd pain.”

• Radiology has trouble reading the handwriting and orders a CT with contrast.

• The patient receives contrast without any pre or post procedure hydration or monitoring.

Where did the systems fail?

• The use of initials and abbreviations has been shown to cause errors.

• The radiology department does not confirm the study ordered when in doubt.

• There is no policy of verifying a patient’s creatinine prior to contrast.

• The secondary diagnosis of renal failure is not included on the ordering sheet.

• The patient was not involved (inquire about allergies, medical history).

Other interesting handwriting examples

Can you tell what drug this is?

Dispensed: PlendilIntended: Isordil

Dispensed: ProzacIntended: Buspar

Dispensed: VasotecIntended: Vantin

Cohen MR. Medication Errors. Causes, Prevention, and Risk Management; 8.1-8.23.

Dispensed: Fiorinal Intended: Florinef

Is it HCT (hydrocortisone) or HCTZ (hydrochlorothiazide)?

Is it six units of insulin or sixty?

Tequin, not tegretolAvandia, not coumadin

Case two: Telephone Medicine

• The wife of a 75 year old man calls the resident’s continuity clinic because her husband is “sick.”

• Paper message slip, generated by triage nurse, is placed on the desk of the resident (the “inbox”) without the chart.

• Paper note discovered two days later by resident, during their scheduled clinic day.

• Chart is requested first; pt not called back until later in the afternoon.

Case two: Telephone Medicine

• Wife states he is febrile and confused.

• Review of the chart reveals pt on high dose prednisone.

• Pt is admitted to the hospital later that day, and dies of overwhelming sepsis.

Where did the systems fail?

• Triage nurse did not ask pertinent questions or review his medical history.

• Patient’s illness prevented him from calling--info obtained second hand, through wife.

• Wife did not appreciate sense of urgency; did not call back after not hearing from clinic.

• Resident in clinic only one afternoon a week.• Message passed to MD without retrieving the

patient’s chart first.

Case Three: Medication Mixup

• Patient comes to a busy ER with history of eye pain after woodworking.

• Patient is to be administered topical anesthetic/fluorescein eye drops and examined for corneal abrasion.

• The resident rotating through the ER instead grabs hemoccult developer bottle, which is the same size and stored in the same drawer below the examining table.

• Hemoccult developer is applied to the patient’s eyes resulting in intense pain.

Where did the systems fail?

• Orient the resident to the ER, exam rooms.• Avoid storing look-alike medications together

so they cannot be mistaken for one another. • Ask the nurse/assistant to set up for the

procedure first, as a “second pair of eyes”.• Or, create separate “kits” clearly marked for

use with all the needed components.• Always verify that the medication or solution

you are about to use is the one intended.• Under time pressure do not take shortcuts but

verify each step in the sequence.

Case Four: Dialysis Patient

• 20 yo female admitted at 6pm for clotted dialysis fistula.

• Patient has a chemistry panel that evening, in which the potassium was not reported. Lab notes: “specimen hemolyzed.”

• Team orders lab to be redrawn, but instead of redrawing that evening, chemistry panel is added on to the am labs.

Case Four: Dialysis Patient

• In the morning, Renal is called for dialysis. The response: “Not our patient, consult Peds Renal.”

• The 7 am lab draw again is reported out as “specimen hemolyzed.”

• No redraw is ordered, and the Renal team has not yet been contacted.

• Team must leave postcall at noon. These issue are passed onto day float.

Case Four: Dialysis Patient

• Technician notes that the t-waves are so tall and peaked on the monitor, that she must adjust the scale to capture the reading.

• After this, she notes QRS widening on the strips. Handwritten note in chart is made, but physicians are not called.

• At noon a code blue is called, patient is in cardiac arrest, a sine-wave rhythm. Stat potassium is 9.4.

Where did the systems fail?

• Outside records were not available. (Was the patient typically dialyzed for volume? Hyperkalemia?)

• Lab does not automatically redraw the hemolyzed specimen, or notify the physician.

• Lab does not report an estimate of the potassium level even if specimen hemolyzed.

Where did the systems fail?

• Ward clerk mistakenly added the redraw onto the morning labs. Computerized physician order entry (CPOE) may have prevented this.

• Technician did not call MD’s with changes on the monitor.

• MD’s did not impress upon nursing or lab that the chemistry panel was essential.

• Due to work hours limits, MD’s had to pass along important tasks to the day float.

Case Five: Discharging a Patient

• Patient with cystic fibrosis is discharged from the hospital from a teaching service after CF exacerbation.

• Discharge medications include NPH and regular insulin.

• Incorrect dose of NPH was written for (twice the usual dose).

• Patient failed follow up appointment.• Three weeks later patient found dead in his

apartment; autopsy revealed extremely low orbital fluid glucose.

Where did the systems fail?

• Intern who wrote the discharge orders wrote incorrect dose.

• Resident who dictated the discharge summary dictated weeks later, did not catch the error.

• Nurse who goes over the medications with the patient on the day of discharge did not notice the change.

Where did the systems fail?

• Pharmacy filling insulin prescription failed to check with MDs or patient regarding dose change (in this case, both prescriptions filled at same pharmacy).

• Patient failed to clarify new dose with the team.

• Patient failed follow up appointment.

Summary of Cases

• Note that in each case, an adverse event was the result of multiple overlapping points of breakdown within the health care system.

• The adverse event was NOT the result of the heinous acts of one individual.

What can we do?

• Recognize that resident physicians are just one part of the system that delivers patient care.

• When you come across a medical error, think, – Where did the systems fail? – What systems, if put in place, could prevent

this from happening again?• Discuss the error with the person (intern, student)

and also attending physician. Focus on the systems issues at hand, and not just the individual.

• Know who to contact at the hospital when a sentinel event occurs.

What can we do?

• Realize that redundancy within the system is often necessary to prevent errors.

• As the senior resident, make your interactions with each component of the system more efficient, more effective, more patient centered.

• Good communication is the key at every level. Suggestions:

The physician-patient interaction• Communicate effectively with the patient

regarding their disease, treatment, prognosis, warning signs.

• Go over medications, including reason for taking, side effects.

• Enlist the aid of the patient’s family and caregivers: “talk to the family.”

• Give the patient written materials whenever possible: UptoDate, Medline Plus.

• Give the patient detailed discharge instructions upon leaving the hospital.

The physician-pharmacy interaction

• Prescriptions/orders should be written legibly, or use electronic ordering systems.

• Write the indication for the drug on the prescription to avoid confusion of “look-alikes” (Celexa, Celebrex).

• When on the wards: use your PharmD.• Cooperate when the pharmacist pages

you to clarify prescriptions.

The physician-nursing interaction

• Shortage of nurses mean fewer nurses caring for more patients.

• Eliminate unnecessary nursing orders to free them up for more important things (i.e. going over discharge instructions.)

• Do you need vitals qid? I/O, daily weight? • Always communicate your plan for the day

with the patient’s nurse or charge nurse.• Always verbally communicate orders that are

especially important.

The physician-1˚MD interaction

• Potential for error very high from the inpatient stay to the outpatient follow up.

• Verbally communicate with the primary MD both during the hospital stay and on the day of discharge.

• Dictate the discharge summaries in a timely fashion and include the important follow up issues—any change in medications, any pending test results, any tests that need to be scheduled as an outpatient.

Objectives

• Define “system”• Recognize the role of systems in

both allowing and preventing medical errors

• List several steps that resident physicians can take to prevent medical errors within these systems: “take home points”

Systems create “latent” errors

• Firing the last person: No help

James Reason.BMJ (2000) 320:768-70