Prevention of Medical Errors
FS 456.013(7)
A Risk Management Seminar for Physicians
Indiana Osteopathic Association
December 8, 2012
Presented by
Debra Davidson, MJ, ARM, CPHRM
Patient Safety Department
Disclosure
We would like to disclose that Debra Davidson,
as an employee of The Doctors Company, has
a financial interest in The Doctors Company, an
organization that may have a direct interest in
the subject matter of this CME presentation.
Prevention of Medical Errors / 2
Course Objectives
At the conclusion of this presentation, participants
will be able to:
• Describe a root-cause analysis
• Recite the most “misdiagnosed” conditions
• Recognize medical error reduction and
prevention measures
• Identify patient safety goals
• Meet the requirements of FS 456.013(7)
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Error Definition
• Adverse Event:
Injury caused by medical management rather than
the underlying illness or condition of the patient
• Malpractice:
Failure to exercise that degree of care used by
reasonably prudent physicians in the same or
similar circumstances
• Medical Error:
A preventable adverse event
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Prevalent Medical Errors
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Nosocomial Infections=103,000 deaths/year1
Medication errors=1.5 million people/$3.5 billion2
Medication errors=7,000 deaths/year2
Allergic reactions=700,000 to ER/year3
Simple errors=27,000 deaths/year4
Wrong Surgeries=1,700-2,700/year5
1 in 20 admissions=preventable adverse event
1. IOM
2. FHA/ASHRM
3. JAMA (10/2006)
4. PIAA Newsbriefs 10.16.2006
5. Archives of Surgery (Sept. 2006)
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“Errors must be accepted
as system flaws,
not character flaws”
—Lucien Leape, M.D.
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Root Cause Analysis
• Structured and process-focused framework
• Credible and thorough
• Active and latent–what, how, and why
 Specific underlying causes
 Reasonably identifiable
 Controlled or influenced
• Generate specific recommendations
Primary aim: Avoid culture of individual blame
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Root Cause Analysis (continued)
MEDICAL ERROR
1. Type of Error
2.
___________
Risk Points
3.
___________
___________
___________
Causal Factors
Processes
Systems
Clinical
Organizational
Corrective
Measures
Corrective Measures
1.________
1. _______
2.________
2. _______
___________
___________
___________
___________
Implementation
1. _______
2. _______
3. _______
3. _______
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3. _______
Measurement of Effectiveness
Root Causes—Medical Errors
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Communication factors
Unclear lines of authority
Highly variable settings
Varied health care processes
Time pressured environment
System deficiencies
Vulnerable defense barriers
Human fallibility
National Patient Safety Foundation
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Most Misdiagnosed Conditions
FAC 64B8-13.005(c) (MD)
FAC 64B15-13.001(3)(f) (DO)*
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Wrong site/wrong procedure surgery
Cancer
Cardiac conditions*
Inappropriate opioid prescribing*
Neurological conditions
Acute abdomen related conditions
Timely diagnosis of surgical complications
Diagnosis of pregnancy related conditions
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Prevalent Types of Error
• Communication Errors
• System Errors
• Medication Errors
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Most prevalent root cause of
medical errors is communication
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Communication Errors
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Failure to educate and inform
Miscommunication
Health literacy issues
Failed crucial conversations
Communication barriers
 Physical
 Emotional
 Cultural
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Effective Communication
• Patients usually interrupted after ____?
• On average, patient would speak _____?
• Short-term investment=long-term payoff
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Improved compliance
Focused interactions
Realistic expectations
Enhanced rapport
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What’s the Trouble?
How doctors think.
by Jerome Groopman, January 29, 2007
Most physicians already have in mind two or three possible diagnoses
within minutes of meeting a patient.
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The New Yorker
Low Health Literacy
• 90 million people have literacy related health risks
• 1 out of 5 read at a _______ grade level
• 50 percent understand directions for taking
medications correctly
www.npsf.org
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Clinician/Clinician Communications
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Referrals
Diagnosticians
Surgical clearance
Hospitalists
Hospitalization
Handoff: SBAR Report
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Situation
Background
Assessment
Response
CHAIN OF COMMAND
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Smart phones
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Communication Error Prevention
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Patient-centric culture
Awareness
Team building
Training
Protocols–checklists
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Eye contact
Slow down
Listen
Language
Visual aids
Limit and repeat
Ask Me 3
Verify with teach back
Preventing Communication Errors
A patient education program
designed to promote communication
between health care providers and
patients, in order to improve health
outcomes.
• What is my main problem?
• What do I need to do?
• Why is it important for me to
do this?
www.askme3.org
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System Errors
• Increase with medical complexity and
numbers involved
• Prevalent adverse events
 Missed diagnosis
 Improper performance–wrong surgery
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System Error: Missed Diagnosis
• Most prevalent conditions
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Cancer
Cardiac
Neurologic condition
Acute abdomen
Complications–Pregnancy
Addiction, psychiatric conditions and diversion
Frequently a concurrent condition
American Prevention of Medical Errors / 25
Missed Diagnosis Root Causes
• Personal bias
• Haste
• Misguided axioms
• Poor history
• Inadequate
follow-up system
• Failure to define
parameters
• Inadequate exam
• Inadequate assignment
of care management
• Failed evaluation
and pursuit
• Faulty communication
of clinical concerns
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Missed Diagnosis: Cancer
• Most prevalent missed diagnosed condition
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60%–Serious injury1
30%–Death1
50%–PCP1
2/3–Cancer1
30%–two or more clinicians
Annals of Internal Medicine 4/2006
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Missed Diagnosed Cardiac Conditions
93%–Chest pain
59%–ECG ordered
50%–ECG misdiagnosed
20%–No study
GI most common diagnosis
<31% attributed a cardiac origin
77%–Died as a result of dx and tx errors
PIAA AMI Claims Study
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Missed Diagnosis: Neurologic Condition
• Clinical examination
 Age
 Traditional vascular risk factors
 Significance of presenting complaints
• Vomiting
 Neurologic examination
• Gait testing
• Vision
 Fixation on other medical conditions
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PIAA AMIPrevention
Study
Missed Diagnosis: Neurologic Condition
(continued)
• Diagnostic testing
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Failure to perform brain imaging
Failure to recognize limitations in imaging
Failure to pursue other diagnostics
Failure to consider in-hospital observation
Failure to obtain neurologic consultation
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Missed Diagnosis: Acute Abdomen
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Appendicitis
• Renal stones
Esophageal varices
• SBO
Abdominal aortic aneurysm
• Hiatal hernia
Peptic ulcer disease
• PID
Hernia of abdominal wall
• Pancreatitis
Cholecystitis/lithiasis
• Colitis
Ectopic Pregnancy
• IBS
Diverticulosis
• Gastroenteritis
GERD
Encountered in 5-10% of all ER visits
PIAA Data Sharing System Report 1985-2007
Prevention of Medical Errors / 31
Missed Diagnosis:
Pregnancy and Its Complications
• Failure to diagnose
 Ectopic Pregnancy
 Gestational Diabetes
 Pre-Eclampsia/Eclampsia
• Failure to diagnose pregnancy prior to treatment
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Routine radiology
Invasive diagnostics
Medications deemed high-risk for pregnancy
Other pertinent treatment initiatives
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Diagnostic Error Prevention
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Triage–H&P
·
Evaluate and document signs and symptoms
Diagnostic pursuit–index of suspicion
Define parameters
Referral and follow-up
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Clarify responsibilities
Manage non-compliance
Monitor follow-up appointments
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Diagnostic Error Prevention (continued)
• Childbearing–testing
• Communicate and document plan
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Education
Diagnostics
Treatment
Follow-up
• Diagnostics
 Physician review
 Communicate
 Tracking/Recall
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Diagnostic Error Prevention (continued)
• Tracking and recall systems
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Failure to follow up diagnostic results–significant
80%–one delay in reviewing results over two months
1 in 5=delays >five times
30%–medical practices fail to document review
Approximately 74 minutes/day managing results
Archives of Internal Medicine. 2009;169(17):1578-1586.
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Data Pending
Patient:
SPECIMENS
Pap
C&S
Biopsy
RADIOLOGY
Chest X-ray
MMG
DEXA
US
___ CT/MRI____
Referral Notes/Records
________ Referrals
________ Records
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Date:
___
____
LABORATORY
CMP
BMP
Electrolyte Panel
Hepatic Function Panel
Lipid Panel
Obstetric Panel
Hepatitis Panel
CBC
PT w/ INR
Hemogram
Amylase
FSH
Glucose________
PSA
TSH_________
UA
Prevention of Medical Errors / 37
System Error: Wrong Surgery
• 58% ambulatory settings
• 29% in-patient OR
• 13% other in-patient settings–ER, ICU
• 76% wrong body part or site
• 13% wrong patient
• 11% wrong surgical procedure
________________________________________
• Communication–78% of cases
• Orientation and training–45% of cases
Joint Commission on Accreditation of Healthcare Organizations
Prevention of Medical Errors / 38
Wrong Surgery Root Causes
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Communication breakdown
Poor patient preparation
Wrong information provided by patient/parent
Errors in consent form and medical records
X-ray interpretation and report language errors
Emergent situations
Unusual time pressure, equipment, or set-up
Morbid obesity
Multiple procedures–multiple surgeons
Clinician error
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Case Summary
• Two (F) patients scheduled for breast surgery on
2/14 by same surgeon
• Surgeon arrived after first patient prepped and draped
• Performed (R) total mastectomy due to breast cancer
• Enters holding area–met by nurse and informed that
his mastectomy patient was “ready”
• First patient scheduled for right breast biopsy only
• Suit
• Disciplinary action
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Surgical Complications
• Most claims have acceptable medical complications
• Failure to supervise/monitor post-op most prevalent
root cause of medical error
• Prevalent post-op complications:
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Infection
Perforation
Suture failure
Bleeding
• Foreign body retention–res ipsa loquitur
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Case Summary
HX:
52 y/o male w/ hx of sleep apnea. Obese. Smoker.
Procedures: R inguinal hernia repair, abdominoplasty,
blepharoplasty
Orders:
Morphine 4 mg IV q 4 h prn.
Valium 2 mg IV q 4-6 h prn.
Monitor. I&O. SCDs. Ambulate ASAP.
Actual Care: Morphine 4 mg IV q 2 h. Valium 2 mg IV q 2 h.
Outcome:
Patient agitated. Restless. Oxygen sats. dropped.
SOB. Vomited. Aspirated. Respiratory arrest.
Code initiated unsuccessfully. Patient expired.
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Wrong-Site Surgery
FAC
(2) “…requiring the team to pause.”
(b) “…The notes of the procedure...”
Florida Statute 456.072(1)
…“Performing or attempting to perform…
… includes the preparation of the patient.
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Department of Health
• Wrong-Site Sanctions (first offense)
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Letter of Concern
$5,000 fine
Costs of investigation and processing (@$2,500)
Five CME’s Risk Management
One hour lecture–develop and deliver
Prevention of Medical Errors / 46
In the News…
Text of Duke's Letter to UNOS
Explaining Transplant Mistakes
Posted: Feb 21, 2003
Durham, NC—The following letter was sent Friday to the United
Network for Organ Sharing (UNOS).
Duke University Hospital has completed the initial phase review of the
events related to the heart/lung transplant from donor _______. We
provide the following to promote our joint efforts in the peer review
of this incident and for the purpose of performance improvement.
We have concluded that human error occurred at several points in the
organ placement process that had no structured redundancy.
Prevention of Medical Errors / 47
West Boca High
cheerleader got
fraction of drug
needed, lawyer
charges
Prevention of Medical Errors / 48
Surgical Error Prevention
• Identification
• Technology–bar-coding/photo ID
• Verification protocol
• Mark site
• Patient education and preparation
• Consent/Education
• Prophylactic ATB
• Protocols
• Training
Prevention of Medical Errors / 49
Surgical Error Prevention (continued)
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Document normal and abnormal findings
Pre and Post-evaluations
Pre and Post-diagnostics
Pre and Post-instruction
Follow-up
Supervision
Team building
Communications
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Medication Errors
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6.5% in-patients–ADEs
Leading cause of harm in hospitals
28% preventable
62%–ordering and transcription
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Top Products—Medication Error
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Insulin
Albuterol
Morphine
Heparin
Cefazolin
Warfarin
Prevention
Medical
Errors / 52
MEDMARX/USP
DrugofSafety
Review
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Furosemide
Levofloxacin
Vancomycin
KCI (potassium chloride)
Curare-type paralytics
Medication Error Root Causes
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Illegibility
V.O. and T.O.
Abbreviations
Multiple medications
Multiple prescribers
Multiple “handoffs”
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Concentrations
LASA medications
Patient understanding
Monitoring
Unfamiliar medication
Coumadin or Avandia?
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Case Summary
CC: Decreased thyroid level
Hx: 52 y/o female treated for three years with
Synthroid. Thyroid level dropped requiring
increase in dosage.
Physician wrote order in progress notes for new
dosage. MA transferred order from progress notes
to prescription pad. Physician used abbreviation for
micrograms. MA used abbreviation for milligrams.
Patient received overdose.
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Official JCAHO “Do Not Use” List
Do Not Use
Potential Problem
Use Instead
U (unit)
Mistaken for “0” (zero),
Write “unit”
IU (International Unit)
Mistaken for IV (intravenous)
or the number 10 (ten)
Write “International
Unit”
Q.D., QD, q.d., qd (daily)
Q.O.D., QOD, q.o.d, qod
(every other day),
q.i.d. (four times daily)
Mistaken for each other
Period after the Q mistaken for
“I” and the “O”mistaken for “I”
Write “daily”
Write “every other day”
Write “four times daily”
Trailing zero (X.0 mg)*
Lack of leading zero
(.X mg)
Decimal point is missed
.2
2 mg
2.0
20 mg
Write “X mg”
Write “0.X mg”
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Abbreviations, Acronyms, and Symbols
Do Not Use
Potential Problem
Use Instead
> (greater than)
< (less than)
Misinterpreted as
the number “7” (seven)
or the letter “L”
Confused for one another
Write “greater than”
Write “less than”
Abbreviations for
drug names
Misinterpreted due to
similar abbreviations for
multiple drugs
Write drug names
in full
Apothecary units
Unfamiliar to many
practitioners. Confused
with metric units.
Use metric units
Prevention of Medical Errors / 58
Abbreviations, Acronyms, and Symbols
(continued)
Do Not Use
Potential Problem
Use Instead
@
Mistaken for the number
“2” (two)
Write “at”
μg
Mistaken for mg (milligrams)
resulting in one
thousand-fold overdose
Write "mcg"
or
“micrograms”
cc
Mistaken for U (units) when
poorly written
Write "ml"
or “milliliters”
Prevention of Medical Errors / 59
LASA Medications
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Klonopin (anti-anxiety)–Clonidine (anti-hypertensive)
Lanoxin (heart failure/AF)–Levoxine (Thyroid tx)
Evista (osteoporosis)–Avinza (extended release Morphine)
Alprazolam (anti-anxiety)–Lorazepam (anti-anxiety)
Lamisil (anti-fungal)–Lamictal (anti-seizure)
JACHO 2005 National Patient Safety
ofAdvisory
Medical Errors
PA-PSRSPrevention
Patient Safety
/ 60
LASA Medications
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Hespan (volume expander)–Heparin (ATC)
Omacor (triglyceride reducer–Amicar (enhances hemostasis)
CIPRO–CIPRO XR
VICODIN–VICODIN ES
Amaryl (antidiabetic)– Reminyl (Alzheimer’s treatment)
Reminyl renamed–Razadyne
JACHO 2005 National Patient Safety
ofAdvisory
Medical Errors
PA-PSRSPrevention
Patient Safety
/ 61
Case Summary
HPI:
22 y/o female c/o persistent abdominal pain
Hx:
Appendectomy w/ p.o. nausea
Plan: Exploratory laparoscopy w/ Anzemet IV
pre-operatively
Outcome: c/o abdominal pain, nausea, extreme
panic apnea → cardiac arrest
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LASA Medications
Zyrtec vs Zyprexa
Prevention of Medical Errors / 63
Medication Error
HX:
9-month-old hospitalized w/ acute asthmatic
bronchitis and pneumonia
Rx:
IM administration of ATB at 75% of
recommended adult dose
Outcome: ATB-induced ototoxicity–permanent deafness
RCA: “NOT FOR PEDIATRIC USE” on label and insert,
Clark’s Rule 13%, no review, no parental warning
Prevention of Medical Errors / 64
Medication Error Prevention
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Electronic ordering or fax
Pre-printed scripts
Brand and generic names
Medication’s purpose
Limit V.O. and T.O.
Refill protocols
Medication history and current profile
Medication/Allergy alerts
Prevention of Medical Errors / 65
Medication Error Prevention (continued)
• Review chart
• Caution with symbols, abbreviations, and
decimals (e.g., 0. and .0)
• Storage and Labeling–LASA
• Limit concentrations
• Written information
• Warnings
• Delegation
• Competency evaluation
Prevention of Medical Errors / 66
In the News…
• Hospital Accused of Overdosing Quaid's
Twin Babies
• Cedars Allegedly Gave Infants 1,000 Times
More Heparin Than Needed
• Posted: 8:40 AM EST November 21, 2007
• Updated: 11:23 AM EST November 21, 2007
Prevention of Medical Errors / 67
Case Summary
CC: 76 y/o w/ shoulder rash
Hx: ED. CAD. ASCVD.
Dx: Ringworm
Tx: Ketoconazole 200 mg; Levitra 20 mg samples
Outcome: Patient expired seven days later–
Acute cardiac episode
Prevention of Medical Errors / 68
MEDICATIONS
Patient:______________________________________DOB: ______________________
Allergies: _______________________________________________________________
Date
Medication
Dose
Frequency
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Samples
Pharmacy
Refill/MD
Refill/MD
Refill/MD
Refill/MD
ANTICOAGULANT THERAPY
PATIENT:_____________________________________________________________
DATE
PT
INR
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DOSAGE
INSTRUCTIONS
INITIALS
Patient Safety Guidelines and
Safety Systems
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Triage
Record keeping
Referral process
Track and follow-up
Assignment of care
Practice guidelines
Communication
Monitor
Education and training
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“Make it easy to do right
and difficult to do wrong.”
- Dr. Lucian Leape
Prevention of Medical Errors / 72
Disclosing Medical Error
FS 456.0575–Duty to notify patients.
Every licensed health care practitioner shall inform
each patient, or an individual identified pursuant to
FS. 765.401(1), in person about adverse incidents
that result in serious harm to the patient.
Notification of outcomes of care that result in harm
to the patient under this section shall not constitute
an acknowledgment of admission of liability, nor
can such notifications be introduced as evidence.
Prevention of Medical Errors / 73
Disclosing Medical Error (continued)
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Seek legal/risk management guidance
Communicate
Express concern/empathy
Do not blame
Present a plan
Confirm understanding
Document
Prevention of Medical Errors / 74
Documentation
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Date, time, and place
Individuals present
Informant(s)
Information conveyed
 Known facts r/t
 Condition, treatment, occurrence
 Immediate and long-term effects
 Current and future interventions
Prevention of Medical Errors / 75
Documentation (continued)
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Questions posed and responses
Offer of assistance
Treatment plan agreed upon
Agreement for follow-up meetings
Reason for incomplete disclosure
Follow-up
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2012 National Patient Safety Goals
• Patient ID
• Medication safety
 Reconciliation
• Prevent infection
• Prevent surgical mistakes
• Communication
• Patient risks
 Recognition and response
Prevention of Medical Errors / 77
Click to edit Master title style
Click to edit Master text styles
 Second level
“The– Fourth
pessimist
complains about the wind;
level
Fifth level
the» optimist
expects it to change;
the realist adjusts the sails.”
 Third level
--William Arthur Ward
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78
Your Role in Reducing Medical Error
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Establish culture
Promote effective team functioning
Anticipate the unexpected
Create an environment of trust and cooperation
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Mission Statement
ddavidson@thedoctors.com
(800) 421-2368, ext. 4005
Our Mission Is to Advance,
Protect, and Reward the
Practice of Good Medicine
For further Patient Safety information,
please visit our Web site at:
www.thedoctors.com
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