Patient Safety 101
for Neurologists
©2012 American Academy of Neurology
Overview
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The history of patient safety
Situations that lead to medical errors
Case studies
How do we avoid medical errors
©2012 American Academy of Neurology
Patient Safety: The History
 Hippocrates – “Primum Non Nocere”
• Beneficence
• Non-malfeasance
 Florence Nightingale
• “It may seem a strange principle to enunciate as
the very first requirement in a Hospital that it
should do the sick no harm.”
©2012 American Academy of Neurology
The History of Patient Safety
 Post-World War II
• Modern advances in the ability of medicine to help were
accompanied by a corresponding increase in the ability to
do harm
 Studies of the impact of medical errors began to appear
in late 1980s to early 1990s
Harvard Medical Practice Study
Reviewed >30,000 charts from randomly selected patients in acute
and non-acute hospitals in New York
o 3.6% of hospitalized patients experienced
adverse events resulting in harm
o 70% of these events resulted in disability lasting
less than 6 months, 13.6% resulted in death,
2.7% permanent disability
©2012 American Academy of Neurology
The History of Patient Safety
 Quality of Australian Health Care Study in 1995
• Placed greater emphasis on quality of care than
negligence, i.e., could the adverse event be prevented?
• Reviewed >14,000 charts from 28 hospitals
16.6% of hospitalized patients experienced adverse events
o 77.1% of those had disability lasting less 12 months
o 13.7% with permanent disability
o 4.9% ended in death
51% of the adverse events were considered preventable
©2012 American Academy of Neurology
The History of Patient Safety
 In early 1995 an epidemic of errors erupted
• Michigan --a surgeon performing a mastectomy on a 69year-old patient removed the wrong breast
• New York--a woman died when a doctor mistook her
dialysis catheter for a feeding tube and ordered food to be
pumped into her abdomen
• Tampa --a 51-year-old diabetic had the wrong foot
amputated and a 73-year-old retired electrician died when
a therapist mistakenly disconnected his ventilator
©2012 American Academy of Neurology
The History of Patient Safety
 Institute of Medicine Report “To Err is Human”
• Landmark paper published in 1999
 Estimated incidence of patients who die in hospital due to
preventable medical error
 Was the springboard for emphasis on patient safety,
quality improvement initiatives, and ultimately pay for
performance
©2012 American Academy of Neurology
What is Medical Error?
 Definition according to IOM
• Failure of a planned action to be completed as intended or the
use of a wrong plan to achieve an aim
• Examples:
adverse drug events
surgical injuries and wrong-site surgery
restraint-related injuries or death
falls
pressure ulcers
©2012 American Academy of Neurology
The History of Patient Safety:
IOM report “To Err is Human”
 Medical error is the 8th leading cause of death in the US.
 Medical errors cause 98,000 deaths per year.
 More people die from medical error than from breast
cancer, HIV, or MVAs.
©2012 American Academy of Neurology
Types of Error
 Diagnostic
• Failure to order appropriate test
• Delay in diagnosis
• Failure to act on results or monitoring
 Treatment
• Error in the performance of an operation, procedure, or test
• Error in administering the treatment
• Error in the dose or method of using a drug
 Preventative
• Failure to provide appropriate monitoring or follow-up
• Failure to provide prophylactic treatment
 Other
• Failure of communication
• Equipment failure
• Other system failure
©2012 American Academy of Neurology
USA TODAY
Thursday, June 28, 2001
Hospital mistakes must
be disclosed
Accreditation at risk if patients aren’t
told
By Robert Davis
Hospitals must now tell patients and
their families when they have been
hurt by a medical error, according to
nationwide standards that take effect
Sunday.
The standards by the nation’s leading
health care accrediting agency are the
first to hold hospitals accountable for
a higher level of patient safety. …
How Unsafe is Healthcare??
Deaths per 100 million hours
Being pregnant
Traveling by train
Working at home
Working in agriculture
Driving
Working in construction
Being hospitalized
©2012 American Academy of Neurology
1
5
8
10
50
67
2000
Cost of Medical Error
 Estimated direct cost of medical error in US $17 billion
 Preventable adverse events to Medicare patients estimated
to cost in excess of $880 million annually
 A study from 2008 revealed overall cost of medical error in
the US to be >$19.5 billion
• Total cost per error approx. $13,000
• >2500 avoidable deaths
• >10 million days of lost productivity at work, costing $1.1 billion in
short-term disability claims
©2012 American Academy of Neurology
Cost of Most Common Medical
Errors
Event
Number of
injuries 2008
% considered
due to error
Medical cost
per event
Total cost per
event
Pressure ulcers
394,699
>90
$8730
$10,288
Post-operative
infections
265,995
>90
$13,312
$14,458
Mechanical
268,353
complication of
device, implant
or graft
10-35
$17,709
$18,771
Hemorrhage
complicating
procedure
35-65
$8,665
$12,272
156,433
©2012 American Academy of Neurology
Why is Healthcare Prone to Error?
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Multiple and varied interactions with technology
Many individuals involved in care
Multiple hand-offs
High acuity of illness
Distracting work environment
Rapid, time-pressured decisions
High volume, unpredictable patient flow
Multiple step processes
©2012 American Academy of Neurology
Why is Patient Safety
Important to Me?
 It can save lives
 It can make YOU a better physician
 It is part of every hospital plan – no matter where


you work
Focused programs are required by the Joint
Commission
It is a required part of resident education
curriculum by the ACGME and RRC
©2012 American Academy of Neurology
How Does This Affect Neurology?
 Many patient groups at risk
• Stroke patients with many comorbid illnesses
Potential for drug interactions
High risk for falls
• Seizure patients with poor compliance or
complex regimens
• Parkinson’s patients and dementia patients
Significant cognitive impairment may result in
medication error
Physical disabilities may increase risk of falls and
injury
©2012 American Academy of Neurology
Of the 300 neurologic lawsuits requiring a pay
out in 2004, most common diagnoses:
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Disc disorder
Stroke
Headaches/migraine
Seizure
Cancer
Meningitis
Paralysis
Aneurysm
©2012 American Academy of Neurology
National Academy of Science’s Institute of
Medicine (IOM)
 In 2001, the IOM laid out six dimensions of quality for

health care.
According to the IOM, health care should be
• Safe
•
•
•
•
•
Effective
Patient-centered
Timely
Efficient
Equitable
©2012 American Academy of Neurology
Patient Safety and Quality Improvement
Act of 2005
 Signed into Law 7/29/05
 Nationwide Goals
• “To encourage the voluntary reporting of medical errors”
• Report to “Certified Patient Safety Organizations”
 Many providers fear repercussions
• Act provides federal legal privilege and confidentiality protection
©2012 American Academy of Neurology
Location of Patient Safety
Organizations by State
©2012 American Academy of Neurology
Joint Commission Goals
 Improve the accuracy of patient identification
• “NEVER” events
 Improve the effectiveness of communication
among caregivers
 Improve the safety of using medications
 Reduce the likelihood of patient harm associated
with the use of anticoagulation therapy
 Reduce the risk of health care-associated
infections
©2012 American Academy of Neurology
Joint Commission Goals
 Accurately and completely reconcile medications
across the continuum of care
 Reduce the risk of patient harm resulting from falls
 Encourage patients’ active involvement in their
own care as a patient safety strategy
 Recognize and respond to changes in a patient’s
condition
©2012 American Academy of Neurology
Crossing the Quality Chasm–
IOM report
• IOM was supposed to be balanced
“…to strike a balance between regulatory and market-based initiatives, and
between the roles of professionals and organizations”
• But it was compliance-heavy
“…to create sufficient pressure to make errors so costly in terms of ability to
conduct business in the marketplace, market share and reputation that the
organization must take action”
IOM Stakeholders
Providers
JCAHO
Establish disease -specific
care performance
indicators and mandatory
reporting for accreditation
Government
Monitor provider
organizations through
mandatory and voluntary
reporting
Implement tools that support
clinical decision making and
prepare for new reporting
requirements.
High quality
SAFE patient
care
Employers
Provide incentives
to providers that use
tools to increase
safety.
Payors
Provide incentives to
providers that use tools to
increase safety and can
demonstrate performance
“Traditional” Patient Safety
Honored traditional teaching
Blame… Shame…
Denial…
Errors are caused by…
Time-honored solutions to error?
Anger… Shoot the messenger…
Work harder…Try harder…
Blame the system…
©2012 American Academy of Neurology
“Culture”
The system of shared beliefs, values, customs, behaviors, and
artifacts that the members of that society use to cope with
their world and one another,
AND
… that are transmitted from generation to generation
through learning.
©2012 American Academy of Neurology
“Culture of Safety”
• Acknowledges high-risk, error-prone nature of modern
health care
• Shared acceptance of responsibility for risk reduction
• Encourages open communication about safety concerns in
non-punitive environment
©2012 American Academy of Neurology
“Culture of Safety”
• Facilitates reporting of errors and safety concerns
• Learns from errors and redesigns safer systems
• Ensures that organizational processes, goals, and rewards
are aligned with improving patient safety
©2012 American Academy of Neurology
MOST COMMON THINGS THAT CAN
RESULT IN HARM TO PATIENTS
#1 MEDICATION ERRORS
1. Medication Errors
 Occur frequently in hospitals
• Approximately 2% of admissions experienced preventable Adverse
Drug Event (ADE)
• Estimated increased cost $5000 per patient
• ADEs cost about $5.6 million per hospital annually
 Average cost per ADE in tertiary hospital $3244 with
increased length of stay (LOS) of 2.2 days
 Average cost per ADE in community hospital $3420 and
increased LOS of 3.1 days
©2012 American Academy of Neurology
Medication Errors
 Most common medications associated with harm
•
•
•
•
•
Anticoagulants
Antidepressants
Antipsychotic medications
Cardiovascular drugs
Analgesics
©2012 American Academy of Neurology
Predictors of ADEs
 Cannot solely be predicted based on patient factors or
drug types
 Some associated risks:
• Older age
• Polypharmacy
• Severity of illness
©2012 American Academy of Neurology
Medication Errors:
What can you do to reduce error or potential
harm?
 Check your orders for accuracy of dosing
 Check medication interactions
 Ask specifically about herbals and OTC products
 Check medication side effects and ask the patient about these on
subsequent visits
 Check to see that the patient is receiving the medication as
prescribed
 Encourage patients to bring in written lists
 Use EHR
©2012 American Academy of Neurology
#2 POOR COMMUNICATION
2. Poor Communication
 In an average 4-day hospital stay, a single patient may
encounter up to 50 different hospital employees
 More than 1/5 of patients reported hospital system
problems
• Staff providing conflicting information
• Not clear who the physician responsible for their care is
©2012 American Academy of Neurology
Poor Communication
 With ineffective communication, great potential for harm
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•
•
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Lack of critical information
Misinterpretation of information
Overlooked change in status
Unclear orders over the phone
 Communication errors identified as the root cause of
sentinel (“Never”) events reported to the Joint Commission
from 1995 to 2004
©2012 American Academy of Neurology
Barriers to Effective Communication
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Hierarchical differences
Inter-professional and intra-professional rivalries
The health literacy of the patient
Differences in language and jargon
Cultural differences
Generational differences
©2012 American Academy of Neurology
Barriers to Effective Communication
 Despite your best efforts to communicate and your belief
that your have communicated effectively, more patients
than you may realize don’t understand what you think
they understand.
 Rarely will patients reveal limitations in their
understanding because they are embarrassed to do so.
©2012 American Academy of Neurology
Barriers to Effective Communication
 Health Literacy - Factors affecting patients’ ability to
understand
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•
•
•
Ability to read
Ability to understand English
Ability to understand medical “lingo”
Cultural / ethnic views of cause and treatment of
disease
• Complexities of health care system
©2012 American Academy of Neurology
What can we do to improve
communication within the health
care team?
 Ensure that the information is conveyed between staff
members at shift changes.
 Written sign out including diagnosis, clinical status of patient,
pending results, key test results, allergies, CODE status, and
“what to do if…”
 If possible, bring the nurse into the room to demonstrate
the current findings and specific things that you want to
be notified about.
 Document the teaching and follow-up.
 ASSUME NOTHING!
©2012 American Academy of Neurology
What can we do to promote
effective communication with our
patients?
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Speak in plain everyday terms– avoid medical jargon
Use teach-back methods
When possible utilize pictures or diagrams
Provide written information or handouts
Make every attempt to use a medical translator for those
patients who are non-English speakers
©2012 American Academy of Neurology
3. Infection Resulting from Lines and Tubes
 Don’t use a Foley catheter unless it is absolutely


necessary.
Lines should be dated and checked daily
Lines should be removed as early as possible, and
if there is ANY sign of infection
As of 2009, CMS and some insurance companies will
not pay for infections that develop once a patient
is in the hospital
©2012 American Academy of Neurology
4. The Patient is Not Sufficiently
Monitored
 Patients may need frequent vitals monitoring, telemetry,
serial lab testing depending on their condition
 No one will fault you for being “overly cautious”
©2012 American Academy of Neurology
5. Handwriting
 Errors in misinterpretation of written orders
account for a large percentage of inpatient
mistakes.
• Avoid use of trailing zeros
Use 5mg not 5.0mg
• Use leading zeros
0.5mg
 Standardized order sets are used to help decrease
orders of OMISSION.
• However may increase orders of COMMISSION due to
duplication of tests or inappropriate medications/tests
 Use of electronic health record systems can
reduce errors caused by handwriting
©2012 American Academy of Neurology
6. The Diagnosis is Not Clear
 A wrong diagnosis is made because of failure to order the
appropriate test
 Always evaluate for life-threatening processes that require
immediate attention (stroke, myocardial ischemia,
pulmonary embolism, intracranial hemorrhage) as
appropriate
 Review all test results in a timely fashion to ensure that
patients are treated appropriately
 Who will notify the patient about their test results? How
will they be notified?
©2012 American Academy of Neurology
7. New Information is Ignored
 Lab results in clinic resulted but not reviewed or patient
not notified of result
 Additional history from patient or family
 A patient admitted for one thing may develop a new
problem while hospitalized
• (e.g., patient with a stroke develops an MI)
©2012 American Academy of Neurology
8. The Patient Who Needs Frequent Blood
Monitoring: Diabetes and Anticoagulation
 Insulin dosing errors in patients who are not eating
 Glucose fluctuations in patients who have infections/stress
of illness
 Increased risk for bleed in anticoagulated patients
 Interactions with other medications
• Ex. Many drugs interact with warfarin and may cause INR to
increase or decrease
• Ex. Antibiotics may interact with and alter levels of anti-epileptic
drugs
©2012 American Academy of Neurology
AND LAST BUT NOT LEAST. . .
THE PHYSICIAN WHO ASSUMES
THAT ERRORS DO NOT OCCUR!
 If we carefully review our work, we are less likely to make
errors
 We should avoid making the same mistakes over againsystem and practice change
“If you don’t have time to do it right the first
time, how are you going to have the time to
go back and fix it later?”
©2012 American Academy of Neurology
CASE STUDIES
Case 1
 Patient admitted to stroke service by night float resident
(or hospitalist). EKG ordered as part of standard order set.
 EKG result not reviewed by the night float (hospitalist);
signed out by phone to the day resident (or next shift)
who has 4 new admits and forgets to check about the EKG.
 Medicine consulted for HTN management 2 days later and
notices EKG with evidence of MI on admit.
©2012 American Academy of Neurology
Case 1: Key Learning Points
 Review all test results and history at time of admission and
also transitions of care
 Adequate handoffs and sign-out are critical, optimally are
written
 Communication between providers is best done face to
face
©2012 American Academy of Neurology
Case 2
 Neurology consulted for patient with delirium in ER
 The patient has history of seizures. Lab tests reveal a
phenytoin level of 65, and patient is ataxic on exam
 Resident does not communicate situation to nursing staff
• Patient is placed in room away from nursing station without
bedrails up, and no falls precautions noted.
 Patient falls out of bed attempting to go to bathroom and
suffers subarachnoid hemorrhage and subdural hematoma.
©2012 American Academy of Neurology
Case 2: Key Learning Points
 Recognition of adverse drug event—supratherapeutic
drug level. Why?
 Failure to follow up on test result
 Communication between providers and care team
members
 Inadequate supervision of falls risk patient
©2012 American Academy of Neurology
Case 3
 Neurology patient admitted to the ICU for status
epilepticus
 Patient seizing for several hours with a low

valproic acid level
Valproate level was not being monitored and was
dosed incorrectly
 ICU team not aware of when to call neurology
 Neurology cross-cover had no sign out for “bed
check” or lab follow-up
©2012 American Academy of Neurology
Case 4
 Patient presented to the ER with mental status
change and found to have a pneumonia.
 Neurology consulted because of strange eye
findings.
 Neurology resident recommended head CT in the
ER but never looked at the scan.
 Patient admitted to medicine for the pneumonia
and never had head CT done until 24 hours later,
which reveals an acute obstructive
hydrocephalus.
©2012 American Academy of Neurology
Case 5
 Patient admitted to stroke service with new atrial
fibrillation and put on warfarin.
 Patient discharged to PCP for follow up.
 PCP never received notification of admission and
discharge recommendations, was not following
INR, and also thought that patient was not a
warfarin candidate because of falls.
 Patient is readmitted for second stroke 30 days
later with INR of 1.1, even though patient
reported compliance with medication.
©2012 American Academy of Neurology
WHAT IS THE IMPACT OF MEDICAL
ERROR ON THE HEALTH CARE
PROFESSIONAL?
Impact of Error on Caregivers
 Surgeons who believed they made medical errors 3 x more
likely to consider suicide (Archives of Surgery)
 Survey by Amy Waterman of 3100 physicians
• 92% reported a “near miss” or a minor error
• 57% reported a serious mistake
• Of those who reported serious error
 2/3 reported anxiety about future error
 50% reported decreased job confidence and
satisfaction
©2012 American Academy of Neurology
How Do We Avoid Medical Errors?
 Recognize the most common errors and take steps to
avoid them
• Review records, orders, admission and discharge information
• Review orders and medications at times of transfer between
units
• Review vital signs daily or more frequently as possible as these
are early signs of changes in clinical status
• Review all test results in a timely fashion
• Identify patients at risk for falls
• Write clearly
©2012 American Academy of Neurology
How to Avoid Medical Errors?
 Review medication lists at EVERY appointment
 Have a formal sign-out or hand-off procedure
 Provide written communication to referring
providers in a timely fashion
©2012 American Academy of Neurology
How to Avoid Medical Errors?
 Make sure there is a clear follow up plan
• Provide appointment on discharge summary for patients
discharged from the hospital
 Provide written information about medications or
diagnoses
 Discuss discharge planning with case managers early so
that patients are not waiting extra days in the hospital for
rehab therapy or home health services to be arranged
©2012 American Academy of Neurology
How to Avoid Medical Errors?
 All of these things take time. . .
BUT
 In the end it saves time and resources by reducing
complications, length of stay, and cost to patients and
systems.
©2012 American Academy of Neurology
WHEN ERRORS OCCUR:
WHAT COMES NEXT?
Disclosing Errors
 Required by the Joint Commission
 Important elements of disclosure that matter most
according to patients
•
•
•
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Disclosure of all harmful errors
An explanation as to why the error occurred
How the error's effects will be minimized
Steps the physician (and organization) will take to prevent
recurrences
©2012 American Academy of Neurology
Disclosing Errors
 Doesn’t mean you talk to the patient or family without
stopping to think first
 You should tell the truth, but tell it wisely
 This means:
• Not withholding key information
• Providing factual information in a timely manner while
acknowledging if there is uncertainty about the course of events
or the consequences of the error
• Speculation ≠ Truth
©2012 American Academy of Neurology
Disclosing Errors Wisely
 First and foremost, when an error happens take
care of the patient
 Once the dust settles, get help
• Physician or nurse supervisors (preferably both)
 Get the facts--and sometimes that takes time
• Was there a departure from a standard of care?
• Was the patient harmed?
• Was the error avoidable?
 Don’t blame, point fingers, or gossip
©2012 American Academy of Neurology
Disclosing Errors Wisely
 Get advice if necessary from Risk
Management, the hospital attorney, or the
ethics committee
 Plan the disclosure—DON’T WING IT
 The most skilled and responsible person
should conduct the discussion
• Should not be delegated to an intern or other
subordinate
©2012 American Academy of Neurology
Disclosure ≠ Liability
 Disclosure is simply a statement that an error happened.
 Liability requires:
• Negligence—departure from standard of care
• Damages—i.e., the patient was harmed
• Proximate cause—the harm resulted from the departure from
the standard of care
©2012 American Academy of Neurology
Summary
 Be aware of the potential for errors across all
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environments and systems in which patients are
cared for
Communication is key!
Remove tubes/lines as early as possible
Practice preventive medicine
• e.g., DVT prophylaxis
©2012 American Academy of Neurology
References
1. Nightingale, Florence. Notes on Hospitals. London: Longman, Green,
2.
3.
4.
5.
6.
Longman, Roberts and Green, 1863.
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and
negligence in hospitalized patients: results of the Harvard Medical
Practice Study I. N Engl J Med 1991;324:370–7.
Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australia
Health Care Study. Med J Aust 1995;163:458–76.
Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a
safer health system. Washington, DC: National Academy Press, 1999.
Leape L, Lawthers AG, Brennan TA, et al. Preventing Medical Injury.
Qual Rev Bull. 19(5):144–149, 1993.
Layde, P. M., Meurer, L.N., Guse, C., Meurer, J. R., Yang, H., Laud, P.,
Kuhn, E.M., Brasel, K.J., & Hargarten, S.W. Medical Injury Identification
Using Hospital Discharge Data. Advances in Patient Safety: From
Research to Implementation. Rockville, MD: Agency for Healthcare
Research and Quality; 2005. AHRQ Publication Nos. 050021 (1–4). Vol.
2;119–132.
©2012 American Academy of Neurology
References
7. Balthasar LH, Keohane C, Seger DL et al. Cost of adverse drug events
in community hospitals. Jt Comm Jour on Qual and Patient Safety
2012; 38:120-126
8. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician
order entry and clinical decision support systems on medication
safety: A systematic review. Arch Intern Med 2003 Jun
23;163(12):1409–1416.
9. Gallagher TH, Garbutt JM, Waterman AD, et al. Choosing your words
carefully: how physicians would disclose harmful medical errors to
patients. Arch Intern Med 2006;166:1585-1593.
©2012 American Academy of Neurology