The Disruptive Physician Federation of State Physician Health Programs 2010 Annual Meeting

The Disruptive Physician
Federation of State Physician Health Programs
2010 Annual Meeting
Doris C. Gundersen, MD
Medical Director
Colorado Physician Health Program
Sentinel Events
Defined by The Joint Commission as:
“Any unanticipated event in a healthcare
setting resulting in death or serious physical
injury or psychological injury to a person or
persons not related to the natural course of
the patient’s illness.”
Examples of Sentinel Events
Loss of limb or gross motor function
 Infant abduction or d/c to wrong family
 Unexpected death of full term infant
 Severe neonatal jaundice (bili > 30mg/dl)
 Surgery on wrong patient or body part
Examples of Sentinel Events
Object left in body post operatively
 Rape in continuous care setting
 Suicide in a continuous care setting
 Hemolytic transfusion reaction
 Radiation to wrong area or 25%> than RX
Sentinel Events
Causal Factors are analyzed
 Systems and processes are reviewed
 Individual performance not reviewed
 Root cause analysis performed
 Action Plan for improvements implemented
 Accredited organization reports to JC ≤ 45 days
Advantages of Reporting
Sentinel Events
Contributing to database (track negative trends)
Dissemination of information for prevention
Joint Commission association serves to reassure the
public and demonstrate the priority of patient safety
Joint Commission
In its root-cause analysis of sentinel events,
the Joint Commission traced 70 percent back
to communication failures.
 We have strived to improve patient care
through technology.
 The human factors are also crucial
Joint Commission, Issue 40
July 9, 2008
Defined Disruptive Behavior as a Sentinel
 Recognition that disruptive behavior can:
– Foster medical errors
– Contribute to poor patient satisfaction
– Contribute to preventable adverse outcomes
– Increase the cost of care (including malpractice)
– Lead to turnover/loss of qualified medical staff
Joint Commission
Goal of including Disruptive Behavior as a Sentinel
– Reform health care settings to address the problem
 There is a history of tolerance and indifference
– Promote a culture of safety
– Improve the quality of patient care by improving the
communication and collaboration of health care teams
Joint Commission Requirements
Hospitals establish a formal Code of Conduct
Leadership creates a process for reporting,
evaluating and managing disruptive behavior
Joint Commission
Educate all team members about
 Hold all team members accountable for
modeling desirable behaviors
 Enforce the code consistently and equitably
 Nonconfrontational intervention strategies
 Progressive discipline