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Patient safety

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Patient safety

  1. 1. Amber Z Jafferi Fort-Night Audit ED
  2. 2.  Patient Centered  Team Based  Risk-Focused  Physician (Frontline) Developed
  3. 3.  S – Sense the error  A – Act to prevent it  F – follow Safety Guidelines  E – Enquire into accidents/deaths  T – Take appropriate remedial  Y – Your responsibility
  4. 4. … Do No Harm…
  5. 5. Variables Adequate Inadequate Not done Wrong entry Pt. Identification Name 130 59 1 68% 30.80% 0.52% MR# 162 27 1 85.20% 14.20% 0.52% Allergies 156 29 5 82% 15.20% 2.60% Date 181 9 95.30% 4.70% Time 156 34 82% 18% Generic names 102 88 53.60% 46.40% Dr Identification Name/Stamp 121 69 63.60% 36.40% ID 175 15 0.92 0.08
  6. 6. Variables Adequate Inadequate Not done Wrong entry Pt. Identification Name 116 50 1 69% 29.90% 0.60% MR# 142 24 1 85.00% 14.40% 0.60% Allergies 142 21 4 85% 12.57% 2.30% Date 161 6 96.40% 3.60% Time 141 26 84% 16% Generic names 97 70 58.00% 42.00% Dr Identification Name/Stamp 102 65 61.00% 39.00% ID 156 11 93.40% 6.60%
  7. 7. Variables Adequate Inadequate Not done Wrong entry Pt. Identification Name 14 9 61% 39.20% MR# 20 3 86.90% 13.10% Allergies 14 8 1 61% 34.70% 4.30% Date 20 3 86.90% 13.10% Time 15 8 65% 35% Generic names 5 18 21.70% 78.30% Dr Identification Name/Stamp 19 4 82.60% 18.40% ID 19 4 82.60% 18.40%
  8. 8. Variables Adequate Inadequate Not done Wrong entry Pt. Identification Name 96 68 3 57.40% 40.70% 1.79% MR# 95 71 1 56.80% 42.50% 0.59% Time 78 89 46.70% 53.30% Past Hx Med Hx 155 12 92.80% 7.20% Drug Hx 52 115 31.10% 69.90% Pain Score Score 104 63 62.20% 37.80% Time 84 83 50.30% 49.70% Post RAT Plan 114 53 68.20% 31.80% Dr Identification Name/Stamp 111 56 66.50% 33.50% ID 135 32 80.80% 32.20%
  9. 9.  Used for  History  Work up  SIGN OUT  HAND OUT
  10. 10. Variables Total Adequate Inadequate Not done Wrong entry Pt. Identification Name 171 122 49 71.30% 28.70% MR# 171 160 11 93.50% 6.50% Physician Name 171 147 24 85.90% 14.10% Time 171 152 19 88.90% 11.10% Allergies 171 141 30 82.45% 17.50% Senior Input 190 141 49 74.20% 25.80% Discharge Diagnosis 190 142 48 74.70% 25.30% Disposition 190 138 52 72.60% 27.40% Instructions 190 133 57 70% 30% Sign Out Name/Stamp 190 121 69 63.60% 36.40% ID 190 119 71 62.60% 37.40%
  11. 11. Variables Total Adequate Inadequate Not done Wrong entry Pt. Identification Name 148 107 41 72.30% 29.70% MR# 148 143 5 96.60% 3.40% Physician Name 148 139 9 93.90% 6.10% Time 148 131 17 88.50% 11.50% Allergies 148 123 25 83.10% 16.10% Senior Input 167 126 41 75.50% 24.50% Discharge Diagnosis 167 126 41 75.50% 24.50% Disposition 167 127 40 76.00% 24.00% Instructions 167 123 44 73.60% 26.40% Sign Out Name/Stamp 167 114 53 68.20% 37.80% ID 167 113 54 67.60% 32.40%
  12. 12. Variables Total Adequate Inadequate Not done Wrong entry Pt. Identification Name 23 15 8 65.00% 35.00% MR# 23 17 6 74.00% 26.00% Physician Name 23 8 15 34.70% 65.20% Time 23 21 2 91.30% 8.70% Allergies 23 18 5 78.20% 21.80% Senior Input 23 15 8 65.20% 34.70% Discharge Diagnosis 23 16 7 69.50% 30.10% Disposition 23 9 14 39.13% 60.86% Instructions 23 10 13 43.50% 56.50% Sign Out Name/Stamp 23 7 16 30.40% 69.60% ID 23 6 17 26% 74%
  13. 13. 1. Identify patients correctly 2. Improve effective communication 3. Improve the safety of high alert Medication 4. Ensure correct site, correct procedure Correct Patient and surgery 5. Reduce the risk of health care associated infections 6. Reduce risk of patient harm resulting from falls
  14. 14. Charles “Chaz” Schoenfeld, MD (1950-2010)
  15. 15. • Up to 80% of serious medical errors involve miscommunication during handoffs (TJC) Up to 24% ED malpractice claims related to handoff (Cheung 2010)
  16. 16. • Production/Time Pressure • High Noise Levels • High Acuity • Multitasking • Time Sensitive Conditions • Rapid Turnover • Frequent Interruptions • New/Unknown Patients • Undifferentiated Diagnosis • Wide Clinical Variation • Increasing Complexity ED Factors – Potentiate Errors
  17. 17. • Neglected/Missed Information • Unclear Transfer of Responsibility • Team Unaware of Transfer/Issues • Patient/Family Unaware • Change in Status • Lack of Mechanism for QA Points of Potential Failure
  18. 18. High Reliability High Risk Process + High Risk Environment Mandates
  19. 19. • Structured • Workable • Predictable • Measurable
  20. 20. “Hopeful Handoff”
  21. 21. • Critical items conveyed? • Safeguards? (Checklist?) • Current clinical status? • Patient aware/Involved? • Nurse aware/involved? Typical ‘Hopeful’ Handoff
  22. 22. • Hope nothing goes wrong • Safe By Luck or Design? • Unstructured – No Standard • Not High Reliability (High Vulnerability) • Poor Strategy for Safety
  23. 23. 1) Record - Critical Data & Pending Items 2) Review - Form & Computer Data 3) Round – Bedside, Together 4) Relay to the Team – Nurse Collaboration 5) Receive Feedback – Clinical/QA
  24. 24. Check if No Patients Signed Out Off-Going Clinician: _________________ Receiving Clinician: _________________ Date (Shift Started)___________ This form is a Quality Assurance Tool and is NOT part of the medical record Safer Sign Out Form (v16) Patient Name & Age Problem List & Key Issues Pending Items Disposition Receiving Clinician’s Notes Diagnosis/CC: Key Issues: Potential Safety Issues or Precautions? Home__________ _________________________ Admit__________ ______________ Transfer________ ______________ NH____________ TBD___________ Rounded on Patient Included/Informed Nurse Diagnosis/CC: Key Issues: Potential Safety Issues or Precautions? Home__________ _________________________ Admit__________ ______________ Transfer________ ______________ NH____________ TBD___________ Rounded on Patient Included/Informed Nurse Diagnosis/CC: Key Issues: Potential Safety Issues or Precautions? Home__________ _________________________ Admit__________ ______________ Transfer________ ______________ NH____________ TBD___________ Rounded on Patient Included/Informed Nurse Diagnosis/CC: Key Issues: Potential Safety Issues or Precautions? Home__________ _________________________ Admit__________ ______________ Transfer________ ______________ NH____________ TBD___________ Rounded on Patient Included/Informed Nurse Room Room Room Room
  25. 25. Safer Sign Out Success Patientsto Sign Out It#is#recommended#to#Sign%out%ALL%patients%that%remain%in%the%department#including#admitted#patients#yet#to#have#admission#orders Key Components 1. Record • Patient, Critical Details, Follow-upItems 2. Review · SSO Form & Computer/ chart Data 3. Round Together • Meet thePatient & AssureaPlan 4. Relay to the Team • Confirm thePlan with theNurse/ Team 5. Receive Feedback • UseSSO Form for Clinical Follow-up& ProcessQA Credits: The Safer Sign Out processwasoriginally developed by the Safety Leadership Group of Emergency Medicine Associates, PA, PC of Germantown, Maryland and will be advanced with the following innovation and research partners: ! ! ! ! ! ! (Safer Sign Out Form Back Page) Best Practices 1) Pre-Round (Off-going clinician) Informing the patient prior to S.O. may help: · Better prepare the patient. · Increase efficiency · Save your colleague’stime 2) Confirm Mutual Understanding Complete the sign out with: “What QuestionsDoYou Have?” 3) Minimize Interruptions 4) Establish a Reliable QA process · Collect & review forms · Encourage Peer Coaching
  26. 26. • Share the Process • Teach Others • Seek Understanding • Pursue Refinement • Regionally/Nationally
  27. 27. • Voice for Safety in Emergency Medicine • National Collaborator • SSO Flagship Safety Tool • Dedicated SSO Website • Consultation Service
  28. 28.  Abstract  --emergency department care work teams designed to improve team communication and coordination and reduce error. The core of this teamwork system is the teaching of teamwork behaviors and skills, development of teamwork habits, and creation of small work teams, all of which are key teamwork concepts largely drawn from successful aviation programs. Retrospective study of ED malpractice incidents. Fifty-four incidents (1985-1996), a sample of convenience drawn from 8 hospitals, were identified and judged litigable or preventable by better teamwork
  29. 29.  An average of 8.8 teamwork failures occurred per case. More than half of the deaths and permanent disabilities that occurred were judged avoidable. Better teamwork could save nearly $3.50 per ED patient visit. Caregivers must improve teamwork skills to reduce errors, improve care quality, and reduce litigation risks. [Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD, The MedTeams Research Consortium: The potential for improved teamwork to reduce medical errors in the emergency department.
  30. 30.  Presented at the annual meeting of the Society for Academic Emergency Medicine, Chicago, IL, May 1998, and the American College of Emergency Physicians Management Academy, New Orleans, LA, May 1998.  Daniel T Risser, PhD , Matthew M Rice, MD, JD, Mary L Salisbury, RN, MSN ∥, Robert Simon, EdD , Gregory D Jay, MD, PhD ∥, Scott D Berns, MD, MPH, The MedTeams Research Consortium
  31. 31.  Allen Kachalia, MD, JD, Tejal K. Gandhi, MD, MPH, Ann Louise Puopolo, BSN, RN, Catherine Yoon, MS, Eric J. Thomas, MD, MPH, Richard Griffey, MD, MPH, Troyen A. Brennan, MD, JD, David M. Studdert, LLB, ScD
  32. 32.  A total of 79 claims (65%) involved missed ED diagnoses that harmed patients. Forty-eight percent of these missed diagnoses were associated with serious harm, and 39% resulted in death.  The leading breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (58% of errors), failure to perform an adequate medical history or physical examination (42%), incorrect interpretation of a diagnostic test (37%), and failure to order an appropriate consultation (33%).  The leading contributing factors to the missed diagnoses were cognitive factors (96%), patient-related factors (34%), lack of appropriate supervision (30%), inadequate handoffs (24%), and excessive workload (23%). The median numbers of process breakdowns and contributing factors per missed diagnosis were 2 and 3, respectively.
  33. 33.  Missed diagnoses in the ED have a complex cause. They are typically the result of multiple breakdowns in the diagnostic process and several contributing factors.
  34. 34.  https://www.acep.org/qipssection  http://www.annemergmed.com/article/S0196- 0644(99)70134-4/  https://www.acep.org/qipssection/  http://www.rcem.ac.uk/

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