When Bad Things Happen to Good Doctors: Patient Safety, Medical Errors, and You Tricia Pil, MD University of Pittsburgh Health Sciences August 26, 2010

Presentation Overview

• • • • • • The scope of medical error Why medical errors happen Practicing safely in an unsafe system Caring for patients after an adverse event Caring for clinicians after an adverse event Acknowledgements and resources

Primum non nocere

First Do No Harm

and yet…

•

The Scope of Medical Error

Every year in the U.S.:

44,000-98,000 people die in hospitals due to medical error.

• Nearly 2 million patients acquire nosocomial infections.

• Medication-related errors cause an estimated 7,000 deaths.

• More than 2/3 of adverse events are preventable, and 28% are due to negligence of a health care professional.

Photo courtesy of IHI Open School for Health Professions, 2010 Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

Brennan T, Leape L, Laird N, et. al. Incidence of Adverse Events and Negligence in Hospitalized Patients. NEJM 1991; 324(6): 370-376.

• • • • • • • • • • • • • • • •

Why Do Medical Errors Happen?

Diagnosing and treating patients is incredibly complex Practitioners not adequately trained or prepared to deliver care as a well-integrated team Flawed processes or systems of care Weak culture of safety in an organization Highly technical equipment Time pressures Fatigue Many caregivers and multiple “handoffs” Limited resources Highly acute or emergent illness and injury Environment full of distractions Variable patient volume Inconsistency or disagreement over what constitutes “best practice” Difficulty keeping up with “the latest” in evidence-based medicine Fear of medicolegal liability impedes reporting and learning from errors Little incentive from insurance companies to reduce errors or reward safety and quality

Reason’s Swiss Cheese Model

• • Quality Improvement means: Every system is perfectly designed to get the results it gets.

Making it easy for people to do things right and hard to do things wrong.

Reason, J. Human Error. New York, NY: Cambridge University Press, 1990.

Practicing Safely in an Unsafe System

Five critical behaviors that YOU can do to improve safety: 1. Follow written safety protocols 2. Speak up when you have concerns 3. Communicate clearly 4. Don’t let yourself or others get careless 5. Take care of yourself

Follow Written Safety Protocols

http://www.tubechop.com/watch/35295

Speak Up When You Have Concerns

• Identify and report issues with policies and procedures • Report unsafe working conditions, near misses, and adverse events • Verbalize concerns

Adverse Event Reporting at UPMC

Other Reporting Options

www.jointcommission.org

www.health.state.pa.us

www.dos.state.pa.us

Communicate Clearly

Communicate Clearly

• • • • Listen to your patient Check for understanding Use SBAR  Situation  Background  Assessment  Recommendation Provide read backs

Don’t Let Yourself or Others Get Careless

June 2009: At an oil drilling rig, company engineers express concerns about well casings that violate their own safety and design guidelines. Yet they proceed.

March 2010: The rig is hit by several gas “kicks” and the blowout preventer leaks fluids at least three times. Still, federal inspectors “pass” the rig.

April 1, 2010, internal memo: Use of cement “against our best practices.” Quality test skipped.

April 18, 2010, internal memo: Improperly centered casings likely to cause “severe” gas flow problem.

April 20, 2010: The Deepwater Horizon drilling rig explodes, killing 11, injuring 17, and causing untold damage to wildlife, coastlines, and local economies. It is the largest marine oil spill in the history of the petroleum industry.

Urbina, Ian. “In Gulf, It Was Unclear Who Was in Charge of Oil Rig.” New York Times 5 June 2010 .

Take Care of Yourself

• • • Be aware of your own physical and emotional limitations, including: Post-call fatigue Illness Stress “Physician, Heal Thyself”?

Revisiting Babel: The Clinician Perspective Patient: We are moved to the postpartum floor. Seven hours later, I suddenly feel weak, dizzy and nauseated. I say, "Somebody help me, I don't feel well." The next minute, I'm hemorrhaging. There is blood spurting everywhere, clots the size of frying pans. I think I am going to die. Panicky nurses and residents crowd the room. The crash cart is wheeled in, my baby is wheeled out. My husband is shouting, "Somebody get Doctor B!" I am being stuck everywhere for an IV. Someone says that there will be a "procedure," and then my underwear is cut off, injections slammed into my buttocks, my legs are forced open and somebody shoves an entire forearm into my uterus and pulls out clots. Three times. I scream and scream and scream. The pain is unbearable, and I feel brutally violated.

Chart: 7:30 am: Called to see patient passing clots. Passed two medium size clots. Blood pressure 110/67…100/60…90/58. Pulse 88…96. Patient uncomfortable, vomited x 2. Bimanual evacuation lower uterine segment with 3 large clots. Orders: IV, Pitocin IV, Methergine IM, Morphine IM, Zofran prn. Discussed with Doctor B.--Intern Hospital: Once again, we refer you back to your private physician for a detailed discussion about the hemorrhage you outlined.

Pil T. Babel: The Voices of a Medical Trauma. Pulse Magazine. 9 April 2010. Web .

20 August 2010.

SILENCE

What to Say to Patients and Families After an Adverse Event

What to Say to Patients and Families After an Adverse Event

1. Tell the patient and “I would like to monitor family what happened.

2. Take responsibility.

3. Apologize.

4. Explain what will be done to prevent questions later on, here future events.

5. Follow up.

is the number to reach me directly.” When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Burlington, Massachusetts: Massachusetts Coalition for the Prevention of Medical Errors; March 2006.

Full Disclosure—Does It Work?

• • • • • The University of Michigan Health System’s Medical Error Disclosure Program showed: Monthly rate for new claims: 36% Monthly rate of malpractice lawsuits: 50% Median time to resolve claims: from 16 to 11 months Mean liability costs: 60% Average costs for lawsuits: from $406K to $228K Kachalia A, Kaufman S, Boothman JD, et. al. Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program. Ann. Intern Med. 2010; 153:213-221.

Impact of Medical Error on Healthcare Professionals: “The Second Victim”

• • • Isolation Shame Self-doubt • • • Grief Guilt Fear http://www.rmf.harvard.edu/education interventions/films/healingthehealer/index .aspx

“I was now forced to confront my own emotional distress and I realized my complete lack of training in how to manage this situation. In an instant, the years of clinical training, my board certification, and the respect of my colleagues as a competent anesthesiologist had become irrelevant and meaningless. I felt lost and alone.” – Rick van Pelt, MD

Barriers to Clinician Support Following Adverse Events

• • • • • • “Perfectionist” educational models Practice “silos” Dysfunctional team dynamics Fear of litigation “Shame and blame” culture Productivity pressures Medical error Adverse event Unsafe practice Emotional distress Maladaptive coping

Future Vision: Elements of an Effective Clinician Support Program

• • • • • • • • • Has visible commitment from executive and medical leadership Is widely publicized, easily, and immediately accessible Offers confidential one-on-one and team peer support Is written in to adverse event policy and procedures Provides clear roles for trained responders Is attentive to individuals involved directly or indirectly in the event Provides proactive training, education, and outreach Is partnered closely with risk, safety, and quality departments Includes periodic follow up Carr S. Disclosure and Apology: What's Missing? Advancing Programs That Support Clinicians. Medically Induced Trauma Support Services; November 2009.

Acknowledgements and Resources

Tricia Pil, MD University of Pittsburgh Health Sciences [email protected]