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Lecture 1: Population Health and Disease Prevention Clinical Care v Population care What influences health outcomes in Deteminants of Health: The broad range of N=1 vs N >> 1 populations?...

Lecture 1: Population Health and Disease Prevention Clinical Care v Population care What influences health outcomes in Deteminants of Health: The broad range of N=1 vs N >> 1 populations? personal, social, economic, and environmental factors determine individual and population HEALTH (WHO): a state of complete physical, Health results when an individuals potential health mental, and social well-being and not merely supported by social and environmental the absence of disease or infirmity determinants suffice to respond satisfactorily * ~70% of population health depends on non- to the demands of life. genetic determinants Population Health: The health outcome of a group of individuals (population), including the The demands of life can be physiological, distribution of such outcomes within the group psychological, or environmental, and they will Medicine is generally practiced (and taught) vary across contexts, but in every case on the predication of a binary labeling system unsatisfactory responses will lead to disease (individuals either sick or healthy), which rarely reflects actual distribution off health and the The Meikirch Model of Health drivers of health in the population Population Health Science focuses on understanding the distribution of health and the causes of these distributions rather thatn the presence, absence, or cause of disease in Social and Environmental Determinants of the individual, ultimately leading to the Health (70%) development of strategies that may reduce > The conditions (factors) in which people are triggers. born, grow, live, work, and age that shape > The interrelated conditions and factors that health influence the health of population over the life course. > Identification of systematic variations in their patterns of occurrence > Application of the resulting knowledge to develop and implement policies and actions to improve the health outcomes of those populations Housing Key Determinant of Health Does where one lives’ affect how long they will Breast Cancer Risk Depends on Where you live? Live Leading Causes of Death Globally > Top 3 are all preventable to some extent through population health management interventions Population Health Manifests as a Continuum Life Expectancy by ZIP Example of Population Health as a Continuum: Example of Population Health as a Continuum: Objective of Population Health Science: BMI BMI > Shift the entire curve of Pop B so that > Population B has a greater prevalence of this population’s BMIs are more like Pop A obesity than Pop A - Overlap distribution of population A and B > Problem? > If we only look at Pop B, we will not realize that those with moderate BMIs have very high BMIs if they were compared to Pop A Population Health Points of Intervention > The Study of population health helps identify the conditions (factors) of intervention. Why Address Role of Social Determinants in Health? > Addressing social determinants of health is the primary approach to: > Achieving health equity > Requires one to look beyond behavioral factors > Addresses the underlying factors related to social determinants of health Health equity is "when everyone has the opportunity to 'attain their full health potential' and no one is 'disadvantaged from achieving this potential because of their social position or other socially determined circumstance” Population Health and Its Aims? Optimize Healthcare Resources: > Population Health: is an approach that aims to > Efficiently allocate and utilize healthcare resources improve the health outcomes of a group of individuals, to achieve max health benefits for population including the distribution of such outcomes within the > Reduce unnecassary healthcare costs and improve group. It encompasses the broad determinants of the cost-effectiveness of healthcare delivery health, such as social, economic, environmental, and Integrate Care Across the Continuum behavioral factors, and seeks to address the >Ensure coordinated and continuous care across disparities and inequities within the population different healthcare settings and providers Engage Community and Stakeholders AIM: Create healthier communities and improve the > Involve community members, policymakers, well-being of individuals within those communities. healthcare providers, and other stakeholders in health improvement initiatives. Improve Health Outcomes: > Foster partnerships and collaborations to address > Enhance overal health status of population by population health challenges collectively preventing dz and promoting healthy lifestyle Data-Driven Decsision Making: > Reduce Morbidity and Mortality Rate > Use health data and analytics to monitor population Address Health Disparities health trends, identify needs, and evaluate the impact >Identify and reduce health inequities among different of interventions populations groups particularly those based on Address Social Determinants of Health: socioeconomic status, race, ethnicity, and geography > Recognize and address the social, economic, and > Ensure equal access to healthcare services, and environmental factors that influence health outcomes. resources > Implement policies and programs that improve Promote Preventative Health Measures: conditions such as housing, education, employment, > Implement and encourage preventive measures and access to healthy fodd. such as vax, screening, and health education. > Foster early detection and intervention to prevent the progression of dz Enhance Quality of Care: > Improve the quality and safety of healthcare services provided to the population > Implement evidence-based practices and ensure patient-centered care Lecture 2: Patient Safety I – Principles of Patient Safety Case Patient Care NOT done well Role of Medical Error in Patient Death What is Patient Safety? A couple took their two-week-old baby girl for a The Process of prevention, amelioration routine check-up. The pediatrician ordered two A 52-year-old woman comes to the emergency (improvement), and avoidance of adverse injuries injections of vitamin. The nurse gave the baby one department because of a 3-day history of severe or outcomes that arise as a result of the healthcare injection and passed the second vial to the chest pains radiating to her left arm and jaw. She process parents. On their way home, the baby cried has a 2-year history of hypertension and continuously. When she suddenly stopped crying, hyperlipidemia and appears in significant distress. REDUCE HARM FROM MEDICAL CARE AND her parents realized she was no longer breathing. The physician suspects acute coronary syndrome ENSURE PATIENT SAFETY They rushed her back to the clinic, where the staff and begins a series of tests, including coronary immediately began to resuscitate. The baby girl angiography. The intervention reveals a critical died later that afternoon. As the grieving parents stenosis (blockage) in the proximal left anterior tried to understand what had happened, they descending artery (LAD). The cardiologist looked at the vial of medicine they had remaining. proceeds with a percutaneous coronary It said EPINEPHRINE. They realized their baby intervention (PCI), inserting a stent to restore blood had not been given vitamin K as they had thought. flow. The woman suddenly goes into cardiac arrest Clinic staff told them that the vitamin K and and fails to respond to resuscitation. A post mortem epinephrine bottles were similar in size and color shows the stent in the left circumflex artery (LCx) and were easy to confuse. “Look-alike” packaging instead of the intended LAD, resulting in is an ever-present challenge in dispensing of inadequate reperfusion of the myocardium. medications. Other Things Can Go Wrong Look-Alike Drug Packaging Who Call: Ensure Patient Safety by developing a better understanding of adverse events in health care: > Causes, How to report, how to lean from mistake, and prevent them Patient Safety is prerequisite of high-quality care. Medical Errors Burden of Medical Errors in the US Medical Errors > The failure to complete the intended plan of > Death certificates in the US, used to compile > Primary and ambulatory Care action or implementing the wrong plan for the care national statistics, have no option for - Delayed Dx of a patient. acknowledging medical error. - Failure for f/u > An unintended act or one that fails to achieve the > The system for measuring national vital stats - Medication error in polypharmacy patient intended outcome should be revised to facilitate better understanding > Hospital Care > Deviations from the process of care, which may of deaths due to medical care - Hospital Acquired Infection or may not result in harm - Wrong-site surgery - Pressure Injury Global Burden of Medical Errors - Venous Thromboembolism > Adverse events due to medical care represetns a major source of morbidity and mortality globally > Mixed > Over 3 million death p/ year - Adverse drug event > 64 Milllion disability-adjusted life years - Dx Error (DALYs) a year - Delayed Dx > Half of all preventable harm in medical care is - Falls medication related > Quarter of which is severe or life- threatening > High Rate of errors in surgical care, intensive care, and emergency care > Unsafe surgical care procedures cause complication in up to 25% of patients > 1 million death annually. > Approx. 2/3 of all adverse events, and the DALYs lost from them, occurred in low-income and middle- income countries > 134 million adverse events each year > 4 in 100 deaths from unsafe care – 2.6 million deaths p/ year > Cost associated w/ medication errors has been estimated at $42 billion > 13% of health spending on treating patients who were harmed in high income Types of Medical Errors - Overarching Distinction Cause of Medication Errors Strategies to Reduce Medication Errors in Medical Errors Patient Specific Causes: Misunderstanding of > Transcription Training medication use (eg elderly patient taking multiple - Avoid using non-standard or ambiguous Medical Errors of Commission drugs or more drugs than necessary), low health abbreviations > doing something wrong (action) literacy and language barrier, economic status - Don’t use U for Units; can look like (eg patient cannot purchase drugs or purchase 0 instead write UNIT Medical Errors of Omission cheaper drugs), cultural factors (eg patient - Avoid Trailing Zeros > Failling to do the right thing (inaction) refuses to take drug or certain drug based on - Don’t write 0.20 or 2.0 mL; write 0.2 or 2 religious beliefs), > Use the 5Rs (five right of medication safety) - Right Drug Drug Specific Causes: Naming, labeling, and - Right Patient packaging of medicines (eg look-alike and sound- - Right Dose alike medication) - Right Route - Right Time Clinician Specific Causes: Insufficient and > Computerized Physician Order Entry (CPOE) inadequate drug training, knowledge, and - Input of orders directly into a computer experience (eg unnecessary drug prescription, system which can automatically check for dosage error, failure to identify a drug allergy), prescribing errors or allergies as per transcribing errors, fatigue, physical and emotional Electronic Health Records (EMR) 1. Medication Errors health issues, administration (eg wrong quantity, > Medication Reconciliation - an error at any step along the pathway that wrong route, wrong drug), math error - Review complete medication regiments begins when a clinician prescribes medication and during patient admission, transfer, Cause of Medication Errors discharge ends when the patient receives the medication Work Environment: Lack of standardized procedures and protocols, insufficient resources, *Medication errors may cause harm to the patient workload, time pressure, distractions, interruptions, 2. Latrogenic or Hospital-acquired Infection (HAI) Adverse Drug Event (ADE) poor physical work environment (lighting, - Prevalence estimated up to 7% in developed and 1. Potential ADE – an error that is intercepted ventilation, heat) 10% in developing before reaching the patient > healthcare and community-associated 2. Preventable ADE – an error that reaches the Computerized Information Systems: Software infection patient and causes some degree of harm errors, difficult process for generating first > Adverse Events and injuries due to medical device 3. Non-preventable ADE – an adverse outcome prescription (drug pick list, missed alert), lack of infection though medications are prescribed and accuracy of patient records, inadquate barriers to - Urinary Catheter-related inf (UTI) administered appropriately - Central line associated bloodstream inf (CLABSI) prevent human error, difficult processes for - Ventilator Associated Events (VAP) generating repeat. **ADEs cause ~1.3 million emergency department Note: Clinician Specific errors are typically result of - Surgical Site Inf (SSI) visits each year. distraction, distortions, or illegible writing. Strategies to Reduce Latrogenic or HAI 3. Patient Falls > Appropriate hand-washing is one of the single > over 30 % of elderly people age >65 fall each most effective methods to decrease infection year in healthcare setting transfer and decrease morbidity and mortality rate > 30-50% of these falls result in injury 1. Increased sink availability > Falls w/ injuries added ~6.3 days to the hospital 2. Increased alcohol-based hand rub stay 3. Use alcohol-based hand rub > Average cost for a fall w/ injury is ~ $14,000 4. Washing hands w/ soup and water 5. Avoiding artificial nails RISK FACTORS 6. Changing gloves after each patient is evaluated - Inadequate site/patient assessment or treated - Communication failure 7. Keep natural nails less than ¼ of an inch long - Lack of adherence to protocols and safrety practices - Inadequate staff orientation, supervision, staffing levels, or skill mix - Deficiencies in physical environment - Lack of leadership Strategies to Reduce Patient Falls - Assessing a patient’s fall risk helps to identify high-risk patient who can benefit from preventive resources > Identity high-risk patients w/ armbands or other visual cues alerting providers of fall risk > Provide safety companions to aid patients who fall > Educate families about fall prevention > Set bed alarms for close monitoring of at-risk patients > Do frequent safety rounds on all high-risk patients Overarching principle -> Close monitoring and support 4. Other Types of Medical Erros Strategies to Reduce Procedural Errors > Unplanned readmissions - The Universal Protocol – A set of guidelines - When patients unexpectantly return to developed by the Joint Commission to prevent hospital < 30 days after being wrong-site surgeries discharged due to: - Premature discharge - 3 Steps - Discharged to inappropriate 1. Pre-procedure verification settings 2. Mark the site - Inadequate information for proper 3. Perform a time-out recovery > All members of the procedure team - Device-related errors (individual performing the procedure, anesthesia - Programming Error providers, circulating nurse, operating room tech, - Incorrect use (eg wrong dose b/c and other active participants agree on: infusion pump is not functioning Correct Patient properly) Correct Site - Documentation Errors Procedure to be done - Software error - Incorrect documentation (wrong patient, wrong date) - Copying and pasting errors - Gaps in record keeping - Mislabeling (eg lab specimen) - Transitions of Care Errors - Inadequate and insufficient handoff communication during shift to shift, transfer, and discharge - Anesthesia errors - Unsafe blood products - Procedural errors - Retained foreign bodies - Injuries to structures (eg paralysis, arterial puncture and bleeding, bowel perforation) - Universal Protocol (time out) – wrong patient, wrong site, wrong procedure Classification of Medical Errors Diagnostic Cognitive Errors 2. Treatment Medical Errors 1. Diagnostic Medical Errors Anchoring bias: When the clinician maintains (is > Failure to correctly administer treatment or Failure to provide an accurate and timely anchored to) initial impressions (what is first seen) perform a procedure explanation of patient’s health problems or when making a diagnosis, and becomes dismissive - eg medication errors, procedural errors, communicate that explanation to the patient to Signs and Symptoms that point to another avoidable delays in administration, “not - Error of delay in Dx diagnosis indicated” care - Failure to employ indicated tests - Failure to interpret test results Confirmation Bias: Looking for evidence and interpretation of information to fit a preconceived * Diagnostic errors account for ~ 17% diagnosis rather than the converse. of preventable errors in hospitalized patients * Availability Bias: More recent and cognitively available answers and solution are preferentially Types of Treatment Medical Errors Types of Diagnostic Errors favored because of ease of recall and incorrectly 1. Slips: 1. No-fault errors: result from factors outside the perceived importance - Actions not carried out as intended or control of the clinician or health care system - ie the most cognitively “available” planned - Atypical disease presentation diagnosis - eg Injecting a medication intravenously - Patient providing misleading info; when you meant to give subQ uncooperative patient Diagnosis Momentum: When the Dx considered 2. Systems-related errors: Result of technical or by one clinician becomes the definitive diagnosis 2. Lapses: organizational flaws as it passed from one clinician to the next; it then - Missed actions and omissions - Inadequate communication and care becomes accepte d w/o question by clinicians - eg forgetting to monitor and replace coordination; inefficient processes; down the line. serum potassium in a patient treated w/ technical failures, and equipment problems furosemide (lasix) for acute congestive 3. Cognitive Error: Diagnosis that are wrong, Framing Effect: Diagnostic decision-making heart failure missed, or unintentionally delayed due to clinician unduly biased by extraneous and collateral error information 3. Mistakes - A wrong but intended action; eg a faulty “Clinicians are frequently unaware of plan or incorrect intention diagnostic errors that they have committed, - eg extubating a patient prematurely based particularly if they do not have an opportunity on misapplication of guidelines to see how their diagnoses turned out over time. Therefore, regular feedback to clinicians on their diagnostic performance is essential…” Not a Type of Medical Error: Violations Outcomes of Medical Errors – 4 Key Outcomes Common Causes of Medical Errors … and How of Medical Errors to Improve Violations: - Communication and teamwork failures - Deliberate actions whereby someone does 1. Near-misses: Errors that occur but do not - Errors at times of transitions or handoffs something and knows it to be against the rules result in injury or harm to patients because they - Stress and fatuque - Eg deliberately failing to follow proper are caught in time or simply b/c of luck - Potential for human error amplified by poor procedures working conditions - Even if action was well-intentioned 2. Adverse Events: Harm or injury that results - Lack of appropriate knowledge and its transfer (quicker, easier, etc), it is still considered a directly from preventable error in medical or - IM SAFE violation surgical treatment rather than by the patient’s - before engaging or attending to a patient - Violations are NOT CONSIDERED A TYPE of underlying disease or condition itself you must confirm IM SAFE (illness, medication, Medical Error stress, alcohol, fatigue, eating) 3. Sentinel Event: An adverse event in which death, permanent or severe temporary harm *The complexity of the healthcare system, coupled (physical/ psychological) or the risk to a patient has w/ the potential for mistakes due to human occurred fallibility, is the primary reason patients experience adverse patient events.* Outcomes of Medical Errors – 4 Key Outcomes of Medical Errors 4. Never Event/ Serious Reportable Events: Adverse events in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility - Surgical or invasive procedure - Product or device event - Patient Protection event - Care Management event - Environmental event - Radiologic Event - Potential Criminal Event 1. Burnout and Fatigue Strategies to Improve Communication Fatigue: the inability to continue effective 1. SBAR | Situation, Background, Assessment, and performance, caused by excessive workload, Recommendation stress, sleep lose, and circadian disruption resulting in sub-optimal patient care and medical Situation errors - Who are you? - Who are you calling about? Burnout: the state of emotional exhaustion, - What is happening w/ the patient? cynicism, depersonalization and decreased sense Background of personal accomplishment that can result in sub- - Why in the hospital? optimal patient care and medical errors - What was previously done? Assessment 2. Communication and Teamwork - What is your assessment based on Lack of appropriate communication + Inadequate available medical findings? team dynamic = Situation where medical errors are Recommendation likely to occur - What do you recommend? 2. Call-out | Inform all team members * Errors at the time of transitions or hand-offs are simultaneously during team events and emergent among the most common communication errors in situations healthcare - Helps create a shared mental model - Helps team members anticipate next steps - Important to direct responsibility to a specific individual responsible for carrying out the task Summary – Outcomes of Error and How to Improve 3 Read-Back | Closed-loop communication where receiever repeats message and sender confirms Error Outcomes - Near misses it’s correct - Adverse events - Ensure that information conveyed by the - Sentinel events sender is understood by the receiver as intended - Never event/ serious reportable events 4. Critical Language | Assertive structured Communication Improvement communication that provides key uniformly - SBAR understood works - Call-out - CUS – I am concerned; I am - Read-back uncomfortable; I think this is a safety issue Lecture 3: Basic Bacteriology I Road Map: Prokaryotes vs Eukaryotes Eukaryotes are organisms whose cells have a Scope of Microbiology nucleus enclosed within a nuclear envelope Cellular: Kingdoms and Domains Prokarotes: Bacteria, Archaea Prokaryotes are single-celled organism which Acellular: Viruses, Viroids (nucleic acid), Three-Domain Sys has a neither a distinct nucleus with a Prions (proteins) - Bacteria membrane nor other specialized organelles - Archaea - Eukarya Six-Kingdom sys - Bacteria - Archaea - Protista - Plantae - Fungi - Animalia Five- Kingdom Sys - Monera - Protista Microbiology is the study of all living - Plantae organisms that are too small to be visible with - Fungi the nake eye - Animalia Bacteriology is the study of bacteria  Prokaryote vs Eukaryotes Prokaryotes Eukaryotes Prokaryotes Cell Morphology: Helps classify Bacteria Gram Staining: Pattern is also used to classif - 80s Ribosome (60S and - 70S Ribosome (50S and 40S subunits) 30S subunits) - Gram- Postitive - Multiple chromosomes - Single circular genome - Gram- Negative - Linear genome - Plasmids * - Atypicals - Membrane-bound - No membrane-bound organelles organelles Shapes: Cocci, Rods, Curved Bacilli (vibrios, - Ex. Nuceleus, ER,etc Spirillum, spirochaete), Cyanobacteria, * Antimicrobial Resistance Gene (AMR) Hyphae Gram Stain Method Gram Stain and Peptidoglycan Bacterial Cell Structure Bacteria are classified by shape and color, Gram Positive Features using Gram stain procedure discovered in - Thick peptidoglycan layer 1882 by Hans Christian Gram - Teichoic Acid 1. Hear Fix Bacteria on glass slide - LipoTeichoic Acid 2. Stain bacteria w/ crystal violet (purple) 3. Apple iodine as a mordant to the crystal Gram Negative Features violet - Thin peptidoglycan layer 4. De-stain bacteria w/ alcohol - Outer membrane 5. Counter-stain w/ Pink Safranin - Porins - Lipopolysaccharide Gram Positive (+) = Purple Gram Negative (-) = Pink * Peptidoglycan layer retains the crystal violet of the Gram Stain Gram-Negative Cell Wall: LPS Cell Wall – Peptidoglycan Lipopolysaccharide – LPS - the Peptidoglycan Monomer is composed of - Part of Outer Membrane 2 covalently bonded sugars w/ amino acids - Only on Gram-Negative bacteria - NAM = n-acetylmuramic acid - LPS has 3 units - NAG = n-acetylglucosamine - “O” Antigen - Pentapeptide chain (5 amino acids) - Polysaccharide - Somatic Antigen for species - Peptidoglycan layer is composed of repeating identification subunits of NAG and NAM, crosslinked by eg. E. coli 0157:H7 sugars and trans-peptide bridges - Core Polysaccharide - Lipid A – Toxic Effect - LPS functions as an endotoxin which triggers inflammation leading to sepsis Cell Wall Targeting - Transpeptidases or Penicillin-Binding Proteins PBPs catalyze the incorporation of the monomer into the adding it to the existing peptidoglycan wall matrix - PBPs are major drug targey for β-lactam drugs, including penicillin Microbial Metabolism Metabolism: Powerhouse of organism Gram-Positive Bacteria Summary Prokaryotes: include bacteria (average 0.2 to 2 uM) - Nucleus w/o a membrane - No specialized or membrane-bound organelles (ribosomes are 70S) - Partial ID done w/ morphology and Gram Stain (crystal violet (purple)), iodine mordant, decolorization (ethanol), contra-stain w/ safranin (pink) - Gram- Positive: Thick peptidoglycan membrane (purple) Teichoic and Lipoteichoic acid - Gram-Negative: Thin peptidoglycan layer sandwhiched between two Gram-Negative Bacteria membrane (PINK), porins, LPS Peptidoglycan: Unique to bacteria - Monomers NAM, NAG interconnected w/ peptide chain - Monomers link w/ a transpeptidase or Penicillin binding protein (PBP) - PBP is target for β-lactam drugs (eg. RX: Penicillin) Metabolism: - Medically important bacteria: Chemoheterotrophs - O2 use: Anaerobic respiration, fermentation, aerobics  Lecture 4: Patient Safety II – Systems Based Practice for Quality Improvement System Approach solves complex system Medical Errors – Simple Truth What is Patient Safety? where the chance of something going wrong Fact: Heathcare systems can achieve “the absence of preventable harm to a patient increases incredible results for even the most severely ill and reduction of risk of unnecassary harm patients associated w/ health care to an acceptable minimum.” BUT… 1. Errors will happen ”The process of amelioration, avoidance, and 2. Systems must be designed to prevent and prevention of injuries or outcomes that arise as absorb them a result of the healthcare process” 3. Errors are not synonymous with negligence. Healthcare Organization Behavior and Culture 4. Most instances of patient harm are the - environmental factors results of BAD systems not bad People - workplace design and process 5. Creating a culture supportive of error - staffing Wrong administration of medication cx of pt reporting is the starting point in reducing future - overcommitment death charged with reckless medical errors. - space homicidhttps://www.usatoday.com/story/news/ Doctors make mistakes… Can we talk about - People nation/2022/05/13/radonda-vaught-gets-no- that? - Time jail-time- Every doctor makes mistakes. But, says - Economic factors medication-error-led-death-patient/ physician Brian Goldman, - scheduling 9761895002/e and abuse https://www.usatoday.com/story/news/nation/2022/05/13/radonda-vaught-gets-no-jail-time- “medicine's culture of denial (and shame) - standardization (reduced variance) - Simplification medication-error-led-death-patient/9761895002/ keeps doctors from ever talking about those mistakes or using them to learn - safety culture and improve.” - integration of care across settings Dr. Goldman tells stories from his own long - over-utilization of resources (antibiotics, practice and calls on doctors to start opiods, imaging) talking about being wrong. Please watch!!! https://www.ted.com/talks/ brian_goldman_doctors_make_mistakes_can_ we_talk_about_that Please also watch!!! https://vimeo.com/ondemand/toerrishuman Designing Systems to Prevent Medical Errors Swiss Cheese Model of Accident Causation Swiss Cheese Model to Study Accident - Some holes due to active failures Causation - Hazards travel threw latent conditions and Case active failures A 45-year-old man presents for treatment of - ERROR GETS to PATIENT acute sinusitis. He forgets to mention his allergy. He is prescribed antibiotics, after which he suffers a severe allergic reaction requiring hospitalization. Despite attempts of resuscitation, the patient sustains a cardiac arrest and dies. Later review of his medical record reveals a documented allergy to the Systems-based approach to failure: Reason’s antibiotic that was prescribed. Swiss Cheese Model Latent Factors: Systems-thinking analysis Organisational Process – workload, Reason’s “Swiss Cheese” Factors The question to be addressed is, “How can the handwritten Rx system be redesigned so it is able to absorb Management Decisions – staffing levels, the error before it reaches the patient?” culture of lack of support for interns - Accident Happening - Error-producing factors Active Failures: Errors taking place between Enviroment- busy ward, interruptions a person and an aspect of a larger system at Team – Lack of supervision the Point of Contact Individual – limited knowledge - Slips, Mistakes Task – Repetitious, poor medication chart - Wrong IV Pump Dose design Programmed Patient – complex, communication difficulties Active Failures - Accident Waiting to Happen - Error – Slips, lapse, violation Latent Conditions: Errors in a system or Defences process design; present but may go unnoticed Inadquate – AMH Confusing for a long time w/ no ill effect Missing – No pharmacist - Faulty equipment, lack of staff training, ineffective organizational structure **Faults (errors) in the different layers of a system - Faulty IV Pump can lead to accidents/mistakes/incidents Swiss Cheese Model Defenses: Defence-in- Swiss Cheese Model for Accident Prevention depth Question: How can the system be redesigned System-thinking analysis so it is able to absorb (catch) the error before it Goal: Redesign system not necessarily to reaches the patient? remove the possibility of error, but rather to create/ reinforce barriers to harm. Answer: Review and add successive layers of defenses, barriers, and safeguards Potential Barriers (Defenses) > Implement a computer physician order entry (CPOE) system based on the patient’s electronic health record, which could have alerted the prescriber and pharmacist to the allergy > Even if the prescriber somehow ignores the CPOE alert, implement additional system in pharmacy to serve as a back-up to prevent the medication error. Swiss Cheese Model Defenses During Pandemics During a pandemic, no single intervention stops spread. However, multiple layers of protective approaches (barriers) will improve success of controlling spread Strategies to Reduce Medical Errors Minimize Interruptions and Institute Safety Situation Awareness (ABC) 1. Human Factors Engineering/ Design Checks across the system Awareness of environment (ergonomics) Independent Double Checks – eg two nurses Belief in your gut feelings The application of psychological and required to check Changing what’s wrong physiological principles to the engineering and Responses required before continuation in design of products, processes, and systems, computer system – eg patient allergy info to reduce human error, increase productivity, “Do not disrupt zone” – eg when entering and enhance safety and comfort w/ a specific medication in computer system focus on the interaction between the human and the thing of interest Focus on high-risk agents/ medication Forcing Functions: Prevents the user from eg. protocolized prescribing, simplified taking an action w/o consciously considering instruction, robust documentation, and use of information relevant to that action standardized administration practices such as Standardization: Implementation and use of dual nurse verification at the bedside, guidelines, checklists standardized labeling, clear storage Simplification: Reduces wasteful activities, requirements increases efficiency, reduces error-prone situations (eg use of EMR) Barcode Labeling across the System - Use barcode labeling of patients, Ergonomics – Other Examples medications, and medical records to Standardize Communication electronically link the right dose of the right - Tall Man Lettering (TML) – uses uppercase medication to the right patient at the right time lettering to help differentiate look-alike drug names. - Starting of the left side of the drug name, capitalizing dissimilar letters Smart Infusion pumps - ex. vinVLAStine versus vinCRIstine, - Infusion pumps w/ dose error reduction CISplatin vs CARBOplatin software (DERS) - Standard abbreviations and numerical conventions – “do not use” list included by the joint Commission - eg IU (international unit) mistaken for IV (intravenous) of note, leading and trailing decimals Error Analysis Tools What is involved in a RCA? Fishbone (Ishikawa) Cause and Effect > RCA is a retrospective approach applied after Diagram 1. Root Cause Analysis (RCA) failure event w/ the goal to prevent its recurrence > RCA is used to identify the causative factors - Always recommended after adverse that underlie variation in performance events - all sentinel events in US are reported > Key purpose is to answer: What, how, and why to the Joint Commission did this happen? Not “whose fault is this?” - Typically sentinel events that results in physical or psychological injury > Uses records and participant interviews to or death are investigaed and identify all the underlying problems that led to an error. analyzed - Causes are identified and systems > Categories of causes include process, people and processes are improved to (providers or patients), environment, equipment, decrease the odds of a repeat material, management. event Case Review – Identify system causes of error and Key Steps During an RCA - Generally, informs the remediation develop action plans that include strategies that 1. Identify and describe the problem clearly. process reduce the risk of future similar events 2. Establish a timeline from the normal situation up The Joint Commission (nonprofit accrediting body, to the time the problem occurred. jointcommission.org) requires healthcare institutions to 3. Distinguish between the root cause and other do a root cause investigation after any sentinel event. causal factors Case: 4. Establish a causal graph between the root cause A provider prescribed erythromycin for a patient and the problem. allergic to erythromycin and the patient developed acute anaphylaxis and died. This sentinel event was reported to The Joint Commission. The hospital is then required to do a root cause investigation which resulted in an action to educate the entire medical staff on drug allergies. The Joint Commission receives a copy of the report. The Joint Commission aggregates all reports and publishes risk- reduction strategies in the “Sentinel Event Alert” newsletter; Failure Mode and Effects Analysis (FMEA) Risk Priority Number Assignment (tool) > A systematic and proactive process of > A numeric assessment of risk assigned to a anticipating failures, determining the impact of process, or steps in a process those failures and determining the likelihood of that 1. What might go wrong w/ a device, product, or failure being detected before it occurs process? 2. What would be the impact of such a failure? > Goal: Prevent patient problems before they occur Risk Priority Number (RPN) > Assumptions: = Severity of Effect S * Probability of Occurence of - FMEA concludes errors will occur even if Cause (O) * Probability of Detection (D) healthcare professionals are careful - FMEA engages in a continual process of RPN = S*O*D quality improvement to assess and correct areas where an error has occurred or is Example: likely to occur Inadvertent esophageal intubation during elective surgery can severely affect patient outcome: RPN = SOD RPN = severe outcome (10) * Low level of occurrence (2) * not easily detected until pt sx (&) = 140 10*2*7=140 Objective: Prioritization: > Identify which failure mode requires corrective action and which risks are acceptable Individual Level Safety Behavior and Culture Components of a Safety Culture Best Method: Systems (not person) based 1. Conducive organizational environment in which approach Flattening the hierarchy – many subordinates, everyone can freely bring up safety concerns w/o fewer levels of management (individual attention to … it is easier to redesign the conditions under fear of censure which people work than to attempt to change subordinate workers) > Facilities error identification fallible human nature 2. Event reporting system collect data on errors for Closed-loop communication (call-back) internal and external monitoring When a system fails (ie medical error occurs), the Psychological Safety (eg reporting errors) immediate question should be WHY did it fail? Not What is reported Who caused it to fail. Near Misses: Not disclosed to patients or families; however, should be reported to the system’s administration so that error can be studied to learn how to prevent it in the future Adverse and Sentinel Events: > Should be disclosed to patient and family, and reported to hospital *Many states have madatory reporting system for Reporting Errors: WHY? adverse and sentinel events > The objective of error reporting is to mitigate > Pennsylvania’s Medical Care Availibility and future errors Reduction of Error (MCARE) act of 2002 > If error-prone situations are reported and > New York Patients Occurence Reporting and managed by modification (redesign) of the system, Tracking Sys (NYPORTS) a decrease in frequency of the error and concomitant errors associated w/ it will occur How should it be done? All known medical errors should be openly disclosed to the affected patient and in certain circumstances their families. NOTE: DO NOT focus of identifying who is What is Needed? responsible w/ a view to take punitive action. It is - Appropriate environment for disclosure estimated that only 5% of patient harm is due - Time, place, and involved persons - Arrangement for f/u care and psychosicial support directly to incompetence or poor intentions. What to do? - Accurate description of the events and their impact on the patient - Sincere apology showing care and compassion - Assurance that steps are being taken to prevent the event from happening in the future. Teamwork Quality Improvement – Systems Level Example: Long Patient Wait Times in the ED - Case Management 1. Standardization – Checklist, guidelines, clinical - Physician Teams pathways, etc. - Physician-physician communication 2. Quality Improvement Models – Plan-do-study - Interprofessional teams act, ergonomics, sigma six, plan-do-check-act - Provider-Patient Communication 3. Quality Measurement – Measurement tools (run - Communication Strategies and control charts), physician quality report system (PQRS), event reporting system, structure/process/outcome/balancing measures 4. High-Quality care – High value, cost control care, equitable care, patient-centered care, timely care *Consider: Strategies to improve quality – Role of leadership, create plan, and roadmap, involve key stakeholders, ensure transparency, prioritize communication Plan-Do-Study-Act (PDSA) Cycles - Four-step cycle that allows one to quickly implement “relatively small-scale” change, solve Notable Benefits of Implementing the PDSA model problems, and iteratively or continuously improve in this setting processes “The success of the first intervention identified - Cyclical nature allow it to be utilized in a another area for improvement as the number of Joint Commission Patient Safety Goals cancellations created space for urgent patients. https://www.jointcommission.org/standards/ continuous manner for ongoing improvement This in turn further improved attendance and national-patient-safety-goals/ reduced the overal waiting time for clinic 1. Plan: Define problem and plan a solution 2. DO: test new process appointments 3. Study: Measure and analyze data 4. Act: integrate new process into regular workflow The Six Sigma Model (6σ) > A data driven approach to solve problems requiring large-scale transformation 1. Define the problem in detail 2. Measure defects 3. Analyze conditions under which defects occur 4. Improve current process to reduce defects 5. Control processes to maintain performance Strategies to Reduce Medical Erros 1. Human Factors Engineering > Ergonomics > Situational Awareness 2. Error analysis tools > Root cause analysis > Failure mode and effects analysis 3. Individual safety behavior and culture 4. Teamwork > Interprofessional Comm > Intra-professional comm > Provider-patient Comm Systems Level Quality Improvement How do we analyze errors? Retrospectively: Root Cause Analysis → Fishbone Proactively: Failure Mode and Effects Analysis → risk priority number assigment Lecture 5: Basic Bacteriology II Bacterial Replication Bacterial Replication Growth Media > Bacterial Reproduce by binary fission > Generation or Doubling Time (g): Time required - Broth or Liquid - One parent cell divides to form 2 progeny for a complete fission replication cycle which varies - Solid agar or Semi-solid cells between organism, depending on conditions - Slant or agar plate 1. Cell replicates its DNA Examples (optimal growth conditions) 2. Cytoplasmic membrane elogates, separating E. coli | 20 min - Bacterial samples are placed in an incubator DNA molecule Staphylococcus aureus | 28 min - Common settings: 35-37 C for 16-48 hour 3. Cross wall forms; membrane invaginates Mycobacterium tuberculosis | 360 min - Some incubators can control CO2 level 4. Cross wall forms completely Treponema pallidum | 1980 min 5. Daughter Cells - Bacteria that require special media or conditions are called fastidious - Ex. M. tuberculosis needs high O2, defined media, takes weeks to grow in BioSafety Level BLS-3 lab Growth Media Selective Media: Contains components that select > β-hemolysis: Complete lysis of red blood cells for the growth of specific organisms. (clear zone) around each colony Rich/ Complex Media: Contains growth nutrients - Limits growth of others from complex biological sources (ie yeast) to grow > α-hemolysis: Partial lysis of the red blood cells a variety of microbes Differential Media: Allows differentiation of (greenish zone) - eg: Trypticase Soy Broth TSB or Tryptic growing bacteria based on different characteristics. Soy Agar TSA - Assists with classification > γ-hemolysis: no lysis - Contains Soybean Meal and Casein to provide macronutrients Ex: MacConkey Agar: Allows for growth of E. Coli and Salmonella restricting growth of other Gram(+) Defined Media: Contains very specific defined bacteria (crystal violett and bile salts) ingredients that are tailored for an organism’s - Lactose is added to identify bacteria that ferment growth requirements lactose w/ a pH indictor (neutral red) - Can be used to determine growth effects on a specific nutrient (ex swapping out glucose for sucrose) Sucrose ……………… 10.0 g K2HPO4 ………………. 1.0 g (NH4)2HPO4 …………. 1.5 g Common Media for Bacterial Identification MgSO4 7H2O ………… 0.1 > Nutrient Agar: rich media for non-fastidious FeSO4 7H2O…………. 0.01 g bacteria MnSO4 7H2O………… 0.007 g > MacConkey Agar: Differential and Selective for Water 985 ml pH 7.0 Enterobacteriaceae > Chocolate Agar: Heated Blood Agar Releases NAD or V Factor for utilization by fastidious organisms > Blood Agar: Enriched differential media w/ TSA plus 5% sheep’s blood Specialized Media (examples) Specialized Media (examples) > Lowenstein-Jensen Agar: Mycobacterium > Thayer-Martin Agar: Neisseria sp tuberculosis - Chocolate agar w/ antibiotics added - Very lipid rich, unique for Mycobacterium (selective) to restrict growth of usual flora tuberculosis Bacterial Quantification Serial Dilution Direct Methods > Calculate the bacteria that are present in the > Agar Plate: Calibrated loop, dilution method (live initial sample (CFU/ mL) bacteria) > Turbidimetric methods: Absorbed light is Formula: CFU = Amount plated mL * Dilution factor proportional to the numer of bacterial cells (spectrophotometer, colorimeter, etc) Values from Sample: # of colonies = 50 CFFU > Electronic counters: Bacteria is passed through - Plated Volume = 0.1 mL * 1:10,000 an orifice placed between 2 electrical poles = 10^-1 * 10^-4 > Microscopic counts: cell count chamber Indirect Methods Reciprocate the denominator: > Nitrogen Content Serial Dilution: when too numerous to count dilute 5.0 * 10 * 10 * 10^4 CFU/mL > Weight sample down > Biochemical Reactions Take the CFU count from a dilution plate that has Concentration of Original Sample = 5.0*10^6 CFU/ between 30-300 Colonies mL Urine Specimen Quantification Colonies = 50 A calibrated loop, either 0.01 mL or 0.001 mL, is Dilution plat = 1:10,000 used to inoculate the entire surface of a blood agar Amount Plated = 0.1 mL plate. One bacteria lands on a media plate and replicates to a visible “colony” UTI => 10,000 CFU – Maximum of two different organisms (more is contamination) #After incubation at 37-C overnight, the colonies are counted and the number is multiplied by the dilution factor, either 100 for the 0.01 mL loop or 1000 for the 0.001 mL, to determine the number of CFUs #of colonies * dilution factor = #CFUs/mL Practice Dilution Factor / CFU Growth Curve Growth Conditions: Temperature (A) LAG Phase Cardinal Temperatures - Newly inoculated cells - Minimum: Lowest Temp, permits growth + - Adjust to new environment Metabolism - Population is sparse or dilute - Maximum: Highest temp permits growth + metabolism (B) EXPONENTIAL (LOG) Phase - Optimum: Small range that promotes fastest growth - Growth occur at an exponential rate and metabolism - Cells reach maximum rate of cell division - Continues as long as nutrients and environment are favorable (C) STATIONARY Phase - Population reaches maximum numbers - Rate of Death = Rate of Multiplication Which Plate should we use? 128 Dilution factor? 10^7 (D) DEATH Phase CFU? 1.28*10^9 - Decline in growth rate - Caused by depletion of nutrients, O2 Growth Curve - Excretion of toxic waste products, > In a closed system w/ fixed conditions, bacteria or increased density of cells (limited follow a growth curve pattern space) Growth Conditions: Temperature Growth Conditions: Water Activity (Aw) Aw = Index amount of water free to react Psychorophiles: Growth best at cold temps < 25-C - Absorption and solution factors reduce Mesophiles: Grow best at human body temp ~37-C availability (low Aw) Thermophiles and Hyperthermophiles = Grow best - Pure distilled water (Aw = 1) vs seawater at high temps >65-C [Archaea] [NaCl] = ~ 3% (Aw = 0.98) > Gram positives can survive in low moisture environments longer due to thick peptidoglycan wall * Pure water - Aw = 1 * Solution Water – Aw will get lower #Exception is Mannitol Salt Agar: 7.5 % salt 8 Nonhalophile: E. coli Halotolerant: Staphylococcus aureus Halophile: Vibrio fischeri Extreme Halophile: Halobacterium salinarum Growth Conditions: pH Neutophiles: Most human pathogens live between pH 6–8 Acidophile: growth at low pH - Lactobacillus as vagina microbiota (ph 4) - Alkaliphiles: growth at high pH due to high levels of minerals (ph 9-11) Growth Conditions: Oxygen Growth Conditions: Oxygen Gram-Positive Bacteria Toxic by product of aerobic respiration: 1. Obligate Aerobe | + SOD, + catalase | Mycobacterium - Bacilli - Superoxide radical O2- Tuberculosis - Cocci - Hydrogen peroxide H2O2 - Need O2 b/c they cannot ferment or respire - Branching anaerobically In order to deal w/ these toxic radicals, bacteria that Gram-Negative utilize O2 usually produce the following 2 enzymes 2. Faculative Anaerobe | + SOD, + Catalase | E. coli - Diplococci - Superoxide dismutase SOD - Can grow w/ or w/o O2 b/c they can metabolize energy - Coccobacilli 2O2- + 2H+ --> H2O2 + O2 aerobically or anaerobically - Bacilli - Catalase - Comma-Shaped 2H2O2 --> 2H2O + O2 3. Aerotolerant Anaerobes | + SOD, - catalase | Streptococcus pyogenes - Do not req O2 as they metabolize energy > By adding Hydrogen Peroxide to clinical samples, anaerobically. Unlike obligate anaerobes however, they Catalase serves as basis for classification for Gram are not poisoned by O2 (+) cocci - Staph species are Catalase (+) 4. Obligate Anaerobes | - SOD, - Catalase | - Strep species are Catalase (-) Clostridioides difficile - Are poisoned by O2 5. Microaerophiles | + SOD, +/- Catalase | Helicobacter pylori - Need O2 b/c they cannot ferment or respire anaerobically. However, they are poisoned by high [O] Summary > Bacteria Replication: Binary fission > Growth Media: - Selective vs Differential - Complex vs Defined - Common media (routine use) vs specialized media (specific organisms) - Bacteria counting: loop or dilution method CFU: Amount (mL) * Dilution factor > Growth Curve: Lag, Exponential, Stationary, Death Phase > Growth Conditions: Temperature: psychrophiles, Mesophiles (Most pathogens), thermophiles pH: Acidophiles, neutophiles pH 6-8 (most pathogens), alkaiphiles Water Activity: Hypotonic, isotonic (most pathogens), hypertonic > Check salt: halophile, non-halophile (most pathogens) Oxygen: Obligate aerobes (SOD, catalase), facultative anaerobe (SOD, catalase, aerotolertant anaerobe (SOD), oligate anaerobe (none), microaerophiles (SOB, maybe catalase) Lecture 6: Bioethics Bioethics Principles, Definitions, and Theories Justice help uphold public trust Bioethics help determine what actions are right or > Procedural Justice: Fairness of law, policy wrong in a given circumstance Principles: > Distributive justice: Criteria for distributing goods, > Bioethics methods are often analytic or empirical - Respect for persons harms, etc 1. principle – proposition underlying a system of ideas, - Beneficence > Social justice: Improve conditions for the least well beliefs, etc - Nonmaleficence off (solidarity – patient vs population DLA) 2. Theory – system of ideas, principles to explain a - Utility thing or action - Justice Respect for Persons 3. Goal – Desired results - Is consistent w/ human rights declarations 4. Guideline – General Rule Classification: - one of five equally important priciples 5. Norm - standard - Goals of Medicine - Each principle complements others - Informed Consent - Belmont Report Patient-Centered Care – Current Standard of Care - Responsible conduct of research - Grounds standards for patient care and informed > Identifies and responds to what matters to each - Research ethics consent in medicine, public health, and research patient - Medical Malpractice - Has ethical and legal implications - Not all catholics adhere to same extent - Medical Battery - Demonstrated by physicians in attitudes, - Communication techniques Elements of Respect for Persons words, and action 1. Fidelity: be loyal to patient, keep promises - Effective use of communication tech Theories: - Social contract of medicine (public trust) - Makes each patient feel cared for (about) - Deontological - Protext patient confidentiality - Improves patient adherence and - Consequential 2. Autonomy: respect individual capacity to choose. outcome 3. Veracity: be truthful to patient - Decreases unnecessary test, Theories 4. Avoidance of Killing: Primum non nocere prescriptions - Withholding and withdrawing treatment do no Deontological – Duty Based Ethics kill Respect for Persons and Codes of Ethics - One of many actions that support - Absent from Hippocratic ethics Consequential – An action is right or wrong depends nonmaleficence > Hippocratic ethics prioritize patient beneficence, not on the consequences that it brings about. autonomy Universal Declaration on Bioethics and Human > Non-Hippocratic ethics emphasize beneficence and Principle Concept Rights (UNDBHR) other principles, responsibilities, and social welfare > Respect for persons emerged 1700s – implies Justice Be fair in distribution, individuals have justifiable moral or legal claims to procedures, etc entitlements or liberties including human rights Respect for persons Show fidelity to patient - Negative Rights: Right to be left alone Beneficence Act in patient intereset - Positive Right: Right to good or service Criticism of Hippocratic Oath Nonmaleficence Avoid harming patient Seen as paternalistic, Religous issues, Cannot keep Utility Balance benefit and harm up w/ modern issues Patient Autonomy and Rights in Medicine What are the Goals of Medicine? What is Professionalism? > Positive rights require physican actions 1. Prevention of disease and injury and the promotion To profess expertise, commitment to a profession or - Be truthful, be fair in providing care, ask and maintenance of health discipline patient preferences 2. Relief of pain and suffering caused by maladies - Involves standards, behaviors, knowledge, > Negative Rights: are passive and do not require 3. Care and cure of those w/ malady and the care of and character action those who cannot be cured - Req knowledge of ethical codes and - Protect privacy, avoid killing, avoid harming 4. Avoidance of premature death and the pursuit of a standards for one’s profession > Autonomy: Individual capacity to determine self- peaceful death. - Professionals are held to high standards interest than non-professionals - Democratic societies grant autonomy to Professional Guidelines Interprofessionalism involves openness to the individuals except when their action impinges As physicians-in-training, medical students are help to perpectives and effects of all health professionals harmfully on others the highest standards of professionalism and have (nurses, veterinarians, etc) - Medicine grants autonomy to patients professional responsibilities that they are obligated to - Actively encouraged by licensing bodies b/c through informed consent and patient uphold. it demonstrates curiosity and willingness to centered care except when their action Guideline are produced by the profession and its consult experts in areas outside medicine impinges harmfully on others regulatory bodies provide consensus guidance on a - ex. One health brings human and veterinary specific topic (clinical, ethical, or other) medicine and public health together to Elements of Informed Consent - Governments, institutions, organization improve diagnosis, treatment, prevention, and - Capacity (CDC, WHO) control of zoonotic and other conditions - Disclosure - Professional Associations, societies (public Contrast professionalism w/ Bioethics - Understanding and private) - Bioethics is the application of ethics to - Voluntariness medicine and health professions, living things, - Authorization and life sciences; and a field w/ peer reviewed Limits of Patient Autonomy journals, books, and qualifications - Harm Principle - Professionalism is a theme that runs through - Diminished Autonomy bioethics, medicine, and other disciplines; like - Paternalism medicine and bioethics, it is learned and - Reportable conditions strengthened over time Professionalism for Medical Students Utility of Prescribing Opiods for Pain Ethical Issues w/ Big Data and AI Should be able to identify: > Goals of medicine say to relieve pain and suffering - Widening of health disparity Common challenges to professionalism > Oral morphine is an inexpensive and effective - Bias - Conflict of interest analgesic - Impact on healthcare workers - Burnout > WHO 3 step ladder (guideline) says treat moderate - Decreased patient interaction - Stress to severe pain aggressively w/ oral morphine - Impact of shared decision making - Exhaustion - eg cancer, post-op, end of life, acute injury or - Cognitive bias illness Summary - Weak communication skills - What about chronic backpain, headache, 1. We distinguished between 2 theories and 5 Consequences of challenges for patients and public injury? bioethics principles, and noted that the principle of trust > The utility (benefit to harm balance) shifts w/ context respect for persons has 4 elements Mechanism for surmounting challenges - The patients’ condition helps to determine 2. Human rights and informed consent are consistent the utility of a treatment w/ the principle of respect for persons (and support Utility = Beneficence + Nonmaleficence positive and negative rights) > Says to consider probable outcomes, probabilities, WHO Guideline – 3 Step Analgesic Ladder 3. Professional guidelines, goals, and ethical codes severity of harm, value of benefit from patient support physician decision-making perspective, and reasonable alternatives to the action Non-opiods 4. Providing ‘patient centered care’ supports respect > And based on above, to act in ways that maximize - eg paracetemol +/- NSAID for persons, autonomy, and informed consent. the net benefit to the patient - Pain {2-5}/10 5. Current ethical codes and guideline in medicine are non-Hippocratic (eg are not paternalistic, and call for Mild Opiods ben