Prevention of Medical Errors PDF

Prevention of Medical Errors Ashley M. Dikis, DPM, FACFAS Assistant Professor Des Moines University  2 objectives 1. Recall the purpose 3. Recognize teams in 5. Recognize the behind patient safety heal...

Prevention of Medical Errors Ashley M. Dikis, DPM, FACFAS Assistant Professor Des Moines University  2 objectives 1. Recall the purpose 3. Recognize teams in 5. Recognize the behind patient safety healthcare concept of Situation initiatives Monitoring 2. Identify the impact 4. Demonstrate 6. Recall how Mutual of using team skills and knowledge associated Support can impact behaviors on patient with the importance of patient outcomes safety leadership in healthcare teams 7. Recognize the necessity of team communication  3 What is a medical Error? A preventable adverse effect of medical care, whether it is evident or harmful to the patient  4 What is a medical Error? 1. Errors of omission 2. Errors of commission M or e ? 4 0 0 ,000 5 44,000 deaths/year 0 0 To Err is Human 0 , 0 Institute of Medicine, 1999 98,000 25  6 The Beginning First time that medical error data was monitored and reported Quality initiatives implemented nationally Majority of medical errors do not result from individual recklessness or the actions of a particular group  7 The Beginning Errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.  8 The Now Bates et al, Jan 2023 Frequency, preventability, and severity of patient harm in 11 Mass hospitals Adverse events in nearly 1 in 4 admissions One fourth of events preventable  9 The Swiss Cheese Model Adverse events are rarely the result of a single human error Multiple flaws (“holes”) in a system’s defense layers (“slices of cheese”) align  10 Design a safer Health System at All Levels Make it harder for someone to do something wrong and easier for them to do something right 1.Who You Gonna Call? Patient Safety Initiatives  n c e b a se 12 vide Patient Safety Initiatives v e l o p as o li d e u a t e u seful 1. De gn and eval ls si oo 2. De egies and t mation and st r a t t e i n for em in a n t a t io n Lacking base of knowledge 3. D i s s o r i m plem e tools f At direction of Congress, the AHRQ was tasked with this project TeamSTEPPS  13 Patient Safety Initiatives Joint Commission Patient Safety Goals Accountability Prevention and education instead of blame and discipline Improve likelihood for reporting Definitions Adverse Event Never Event Near Miss  14 Patient Safety Initiatives American Council of Graduate Medical Education (ACGME) Mandates formal education in patient safety Lack of standardized method Traditionally online learning modules or didactic lectures (passive) Goolsarran et al 2018 Trainees demonstrated statistically significant increase in knowledge specifically related to patient safety core concepts  15 Patient Safety Initiatives Obstacles can lead to error and be detrimental to performance: Excessive professional courtesy Halo effect Passenger Syndrome Hidden agenda Complacency High-Risk Phase Task Fixation Strength of an Idea Hazardous Attitudes 2. You’ve Got A Friend In Me Teams in Healthcare  17 Teams in Healthcare Open and frequent communication between patient, providers and staff Everyone clear on their roles and responsibilities  18 Teams in Healthcare Large body of literature suggests that effective teamwork in healthcare is associated with: 1. Reduced medial errors 2. Increased patient safety 3. Improved patient satisfaction 4. Reduced stress in workers 5. Improved job satisfaction 6. More effective use of resources 7. Reduced physician visits and hospitalization rates 3.Who’s the boss? Leadership  20 Leadership – What makes an effective team leader? Organize team Identify and articulate goals Assign tasks and responsibilities Monitor and modify plan; communicate changes Review team’s performance and offer feedback Manage and allocate resources Facilitate information sharing Encourage team members to assist each other Facilitate conflict resolution Model effective teamwork  Brief: Short session prior to start— 21 Leadership share plan, team formation, roles and responsibilities, expectations Huddle: Re-establish situational awareness, assess need to adjust plan Debrief: Informal info exchange BRIEF designed to improve team performance and effectiveness through lessons learned and positive reinforcement HUDDLE DEBRIEF 4. This Is Fine Situation Monitoring  23 Situation Monitoring Process of continually scanning and assessing a situation to gain and maintain an understanding of what’s going on around you Everyone on the same page  24 Situation Monitoring  Situation Monitoring S T E P 25 Status Team Environment Progress History Fatigue Facility Info Status of Patients Vitals Workload Admin Info Estab Goals Meds Task Performance HR Tasks/Actions Physical Exam Skill Triage Acuity Plan Still Plan of Care Stress Equipment Appropriate? Psychosocial 5. I’ve Got Your Six Mutual Support  27 Mutual Support Task Assistance Helping others with tasks Protect each other from work overload Place all offers for assistance in context of patient safety Foster climate where it is expected for assistance to be both sought and offered Burnout  28 Mutual Support Feedback Purpose of improving team performance Timely: given soon after target behavior occurred Respectful: focus on behavior, not personal attributes Specific: relates to specific task or behavior that requires correction or improvement Directed: provides direction for future improvement Considerate: considers a team member’s feelings and delivers negative info with fairness and respect  29 I am ! e rne d conc I am uncomfortable! Voice concerns Two times Confirm acknowledgement Take stronger course or utilize chain of command This is a safety issue! “STOP THE LINE” 6. I love When a Plan Comes Together Team Communication  31 Team Communication SBAR Situation: What is going on with the patient Background: What is the clinical background or context? Assessment: What do I think the problem is? Recommendation and Request: What would I do to correct it? “I am calling about Mrs. Joseph in room 251. CC is new onset SOB. She is a 62 y/o F POD1 abdominal surgery. No hx of cardiac or lung dz. Breath sounds are decreased on R with acknowledgement of pain. Would like to r/o pneumothorax. I feel strongly the patient should be assessed now. Can you come to room 251 now?”  32 Team Communication Call-Out Informs all team members during emergent situation Helps team members anticipate next steps Important to direct responsibility to specific individual Check-Back Closed-loop communication Initiation – Feedback - Confirmation  33 Team Communication Handoff Important during shift or call exchange Traditionally a weakness in GME  34 “Physicians are socialized in medical school and residency to strive for error-free practice. There is a powerful emphasis on perfection, both in diagnosis and treatment. In everyday hospital practice, the message is equally clear: mistakes are unacceptable. Physicians are expected to function without error, an expectation that physicians translate into the need to be infallible. One result is that physicians, not unlike test pilots, come to view an error as a failure of character—you weren’t careful enough, you didn’t try hard enough.” Lucian Leape, MD “Error in Medicine” JAMA 1994  35 What’s the solution?  36 Summary Patient safety initiatives Teams in healthcare Leadership Situation monitoring Mutual support Communication Condition of the Practitioner  37 References 1. Goolsarran et al. Effectiveness of an interprofessional patient safety team- based learning simulation experience on healthcare professional trainees. BMC Med Ed 2018; 18: 192. 2. Durstenfeld et al. The Swiss Cheese Conference: Integrating and Aligning Quality Improvement Education With Hospital Patient Safety Initiatives. Am J Med Qual 2019; 34(6): 590-595. 3. West et al. Illusions of Team Working in Health Care. J Health Org Management 2013; 27(1): 134-142. 4. Latif et al. Evaluating Safety Initiatives in Healthcare. Curr Anesthesiol Rep 2014; 4: 100-106. 5. Sunshine et al. Association of Adverse Effects of Medical Treatment With Mortality in the United States. JAMA Network Open 2019; 2(1): 1-14. 6. L. Leape. Error in Medicine. JAMA December 21, 1994; 272 (23): 1851-1857. 7. Pocket Guide: TeamSTEPPS. Content last reviewed January 2020. Agency for Healthcare Research and Quality, Rockville, MD. 8. S. Yates. Physician Stress and Burnout. Am J of Med 2020; 133-164. 9. TL Rodziewicz. Medical Error Reduction and Prevention. StatPearls, 2022. 10. Bates et al. New England J Medicine 2023; 388(2): 142-153.  38 Presentation template by SlidesCarnival Thanks! Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws.