Transcript Slide 1

Patient Safety in
Ambulatory Care
ECMH Grand Rounds
February 22, 2013
Donna Woods, EdM, PhD & Dan Evans, MD, MS
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INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
ECMH Updates
• No Grand Rounds next month
• Student surveys coming this weekend…
• Next month each clinic will be receiving a QI
scorecard & will be asked to design at least 1 PDSA
• Clinic attendance…
• Follow ECMH on twitter
https://twitter.com/devans_at_NUmed
• Or try our new webpage:
• http://www.feinberg.northwestern.edu/education/c
urriculum/learning-strategies/education-centeredmedical-home/index.html
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Overview
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Definitions
Epidemiology of Risk in Ambulatory Care
Specific Areas of Focus
ECMH Patient Cases
ECMH Team Discussions of Approaches
Report Out and Discussion
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Definitions
• Patient safety: Freedom from accidental injuries.
• Error: The failure of a planned action to be completed as intended (i.e.
error of execution) or the use of a wrong plan to achieve an aim (i.e. error
of planning) (3). Errors may be errors of commission or omission, and
usually reflect deficiencies in the systems of care.
• Adverse event: An injury related to medical management, in contrast to
complications of disease (4). Medical management includes all aspects of
care, including diagnosis and treatment, failure to diagnose or treat, and
the systems and equipment used to deliver care. Adverse events may be
preventable or non-preventable.
• Preventable adverse event: An adverse event caused by an error or other
type of systems or equipment failure (5).
• “Near-miss” or “close call”: Serious error or mishap that has the potential
to cause an adverse event but fails to do so because of chance or because
it is intercepted.
• Hazard: Any threat to safety, e.g. unsafe practices, conduct, equipment,
WHO Guidelines for Adverse Event Reporting and Learning Systems
labels, names.
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Epidemiology
1999
Institute of Medicine Report
To Err is Human: Building a Safer Health System
 44,000-96,000 preventable adverse
events occur each year in the United
States
 5th leading cause of death
 Estimated costs of 38 – 50 million for
adverse events (4% of healthcare
costs).
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New Epidemiology
2010
 180,000 preventable adverse events
occur each year in Medicare patients
in the United States
 13% of Medicare beneficiaries
experienced at least one adverse
event resulting in serious patient
harm
 5th 3rd leading cause of death
 Estimated costs of 38 – 50
Billion for adverse events
19.5
Department of Health and Human Services
Office of the Inspector General: Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, November 2010,
OEI-06-09-00090. http://oig.hhs.gov/oei/reports/oei-06-09-00090.pdf. Accessed January 5, 2012.
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
47% of People Concerned about
Errors in Hospitals
(Kaiser/AHRQ, 2000)
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
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Student Presentations
ECMH Cases
What safety issues have you seen in
your clinics recently?
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INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Studying Ambulatory
Adverse Events
• Ambulatory events leading to hospital
admission
• Events detected in electronic system
• Malpractice claims
• Collection of provider reports
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INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Adverse Events in
Ambulatory Care Settings
• Based on the Conservative
IOM Data
• Ambulatory events leading
to hospital admission
– ~171,000 discharges annually
in the US related to
ambulatory care adverse
events
– ~76,000 discharges annually
related to ambulatory care
preventable adverse events
Woods et. al., QSHC, 2007
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Ambulatory Care
Preventable Adverse Event Types
Event Type
• Preventable Adverse Events
– Diagnostic
– Surgical
• Harm
– Surgical (X = 4.0)
– Diagnostic (X = 3.4)
– No significant difference
among the others
Preventable Adverse Events
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Ambulatory Care
Preventable Adverse Events
Ambulatory Care Setting Type
Preventable Adverse Events
• Most common setting of
Preventable Adverse
Events
– Physician’s Office
– ED
– Home
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• Mean Harm
– Highest in Ambulatory Surgery
– Diagnostic
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Ambulatory Care
Preventable Adverse Events
Ambulatory Care Provider Type
Preventable Adverse Events
• Preventable Adverse
Events
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– Primary Care
– Emergency Medicine, Medical,
and Surgical Specialties
• Harm
– Primary Care (X = 4.0)
– Emergency Medicine, Surgical
and Medical Specialties (X =
2.5 – 3.0)
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Breakdown Points in the
Diagnostic Process in Ambulatory Care
Gandhi, T. K. et. al. Ann Intern Med 2006;145:488-496
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Communication
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Frequency of Lab Testing Errors
243 physicians reported 639 reports with 1010 errors
Error Category
Physician
Ordering the test
Implementing the test
Reporting results to the
clinician
Clinician responding to the
results
15%
20%
28%
Patient notification
6%
Administration
15%
5%
Other process errors
5%
Dovey SM, Meyers DS, Phillips RL Jr., et. al. A preliminary taxonomy of medical errors in family practice. Qual Saf Health Care. 2002 Sep;11(3):233-8
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Outpatient Medication Safety
• In a seminal study of 24 outpatient
practices
– 1879 prescriptions from 1202 patients
– Outpatient medication errors in 27 of 100
patients
– 62 (3% of all prescriptions) had potential
for patient injury (potential ADEs);
– 1 was potentially life-threatening (2%) and
15 were serious (24%).
– Errors in frequency (n=77, 54%)and dose
(n=26, 18%) were common.
– Advanced checks (including dose and
frequency checking) could have prevented
95% of potential ADEs.
Ghandi TK, Weingart S, Seger AC, et. al. Outpatient Prescribing Errors and the Impact of Computerized Prescribing. Journal
of General Internal Medicine, 2005; Volume 20, Issue 9, Pages 837-841
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Adverse Drug Events in
Ambulatory Care
• The rate of outpatient ADEs
may be ~4 X as high as that
reported in hospital studies
and
• More than one third of
these events are
preventable
• Number of medications
significantly associated with
adverse events
Gandhi et. al. 2003
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Ambulatory Care Medication Adverse Events
• Forty (70%) of the preventable
ADEs were related to parent drug
administration.
• Improved communication
between health care providers
and parents and improved
communication between
pharmacists and parents,
whether in the office or in the
pharmacy, were judged to be the
prevention strategies with
greatest potential.
Kaushal, et. al., 2007
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ASIPS Study:
Frequency of Errors
475 physicians submitted 608 reports
Error Category
Physician
Administrative
Lab testing and imaging
34%
25%
Medications and treatment
Problems related to both
Medications and diagnostics
23%
14%
Fernald DH, Pace WD, Harris DM, West DR, Main DS, Westfall JM. Event reporting to a primary care patient safety reporting system: A
report from the ASIPS Collaborative. Ann Fam Med. 2004 Jul-Aug;2(4):327-32
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AAFP National Research Network
Error Reports
42 physicians made 344 reports
Error Category
Physician
Administrative
Lab testing and imaging
Medications and treatment
Error in the execution of a clinical task
Wrong diagnosis
Wrong treatment for diagnosis
34%
25%
23%
6%
4%
4%
Dovey SM, Meyers DS, Phillips RL Jr., et. al. A preliminary taxonomy of medical errors in family practice.
Qual Saf Health Care. 2002 Sep;11(3):233-8
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Australia Error Reports
324 GPs reported 805 incidents in 1993-1995
Error Categories
Proportion
Medication issues
Treatment issues
Delayed or missed diagnosis
54%
43%
34%
Bhasale AL, Miller GC, Reid SE, Britt HC. Analyzing Potential Harm in Australian General
Practice: An Incident-Monitoring Study. Med J of Australia 1998;169:73-76.
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Ambulatory Adverse Events
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Diagnostic errors:
 Most frequent and most harmful
 Range from trivial failures (overlooking a minor lab
abnormality) to more serious errors (switching of
specimens between two patients)
 Seven stages in the diagnostic process, with potential
for error at each stage:
 Access and presentation; history taking; physical
examination; testing; assessment; referral; and
follow-up
•
Communication errors:
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Hospital discharge communication
Research on follow-up of tests pending at discharge
Discontinuity of care at care transitions
•
Communication of test results
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Communication and non-adherence
Between-team communication

Medication safety:
Drugs widely used, with narrow therapeutic
ranges and high toxicities associated with
ADEs and/or medication errors
Elderly, taking many medications,
comorbidities
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 Medication reconciliation
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
How do we achieve safety
in health care?
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Safe Culture
Safe Systems
Safe People
Error (event) reporting, surveillance, and
other data gathering methods inform
improvement
• Improvement Methods
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
High Reliability Organizational
Principles of Safe Culture
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Preoccupation with failure
Reluctance to simplify
Sensitivity to operations
Commitment to resilience
Deference to expertise
Continuous Learning and Improvement
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Changing the Paradigm
“Everything’s Fine”
Out
In
All is fine
Errors are rare
Tell as little as you can
Keep Board out
MDs don’t participate
Our error rate is average
Endless opportunities for improvement
Errors everywhere
Tell whatever you can
Actively involve Leadership
Docs actively involved
No threshold for errors
INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
CUS
• C Concerned
• U Uncomfortable
• S Safety Issue
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INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Student Presentations
ECMH Cases:
What safety issues have you seen in
your clinics recently?
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INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
• ECMH Teams Meet to discuss challenges in your
ECMH home
• How common are medical errors?
• What is the proper student response when confronted with a medical
error about to happen?
• What is the proper student response when confronted with a medical
error that has already occurred?
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Should the student report it?
How ?
When?
To whom?
Is there a support number or contact for students to call?
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Hypothetical scenarios:
• You’re an M4 student and you are excited that
Epic allows you to write medication orders –
you write a new script for glyburide for your
85 yo diabetic and you realize the next week
that you had accidently doubled the dose and
your attending signed your script without
catching the error…
• Reportable? How? When? To whom? What if
you just asked your for a letter of rec?
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INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Hypothetical scenario:
• You’re an M3 student . You are following your
patient’s progress remotely. Last week your
patient needed a script for his tuberculosis
meds called into the pharmacy. You had asked
your attending to e-Rx the meds, and you
reminded him again at the end of clinic
huddle. One week later there’s no script…
• Reportable? How? When? To whom? Do you
feel comfortable calling your preceptor?
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INSTITUTE FOR HEALTHCARE STUDIES • FEINBERG SCHOOL OF MEDICINE
Hypothetical scenario:
• You’re an M2 student . You go visit your 84 yo
patient in the hospital who was admitted 3
days ago for failure to thrive. You find she has
a foley catheter (not indicated), her med list
was changed (ambien & benedryl were added)
and the team is ordering a CT scan to look for
PE (but her GFR is 30). You have some safety
concerns…
• Reportable? How? When? To whom? Are you
comfortable voicing concerns to hospitalist?
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Discussion
& Wrap-up
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