The Knowledge Imperative Timothy B McDonald, MD JD September 7, 2012
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1 The Knowledge Imperative Timothy B McDonald, MD JD September 7,
2 SESSION DESCRIPTION Interactive session on the role of science in patient safety that will address how knowledge, skills and behavioral competencies are critical to reducing errors. Implications and opportunities for medical students 2
3 HOW SONIA HAS ALWAYS FELT ABOUT LAWYERS
4 Human factors science research examines the environmental, organizational and job factors of humans interacting with systems, as well as the physiological and psychological characteristics which influence behavior at work. 4
5 Medical Student 5
6
7 A CASE TO ILLUSTRATE THE IMPORTANCE OF KNOWLEDGE, SKILLS, AND BEHAVIORAL COMPETENCIES IN ERROR REDUCTION July 17, 2012 Post-operative patient has routine labs drawn at midnight At 2 am -hemoglobin reported as 7.1 gms/dl First year resident physician called Orders patient to receive one unit prbcs Concerns? 7
8 TIMELINE 7-9 THRU
9 A CASE TO ILLUSTRATE THE IMPORTANCE OF KNOWLEDGE, SKILLS, AND BEHAVIORAL COMPETENCIES IN ERROR REDUCTION On July 9, 2012 patient was admitted with altered mental status and unable to communicate. Discussion with patient s mother revealed that patient was a Jehovah s Witness. Consented to the administration of fresh frozen plasma, platelets. Refused to consent to prbcs New concerns or questions? 9
10 A CASE TO ILLUSTRATE THE IMPORTANCE OF KNOWLEDGE, SKILLS, AND BEHAVIORAL COMPETENCIES IN ERROR REDUCTION Back to July 17, am bedside nurse sends clot to blood bank 5 am blood bank sends unit of prbcs Bedside nurse asks charge nurse to double check consent Charge says to go ahead consent in order Nurse begins to administer blood 7 am next shift arrives, alarmed to see blood hanging Concerns, questions, what next? 10
11 A COMPREHENSIVE RESPONSE TO PATIENT INCIDENTS: THE SEVEN PILLARS. MCDONALD, MAYER ET AL. QUALITY AND SAFETY IN HEALTH CARE, JAN 2010 Reporting Investigation Communication Apology with remediation including waiver of hospital and professional fees Process and performance improvement Data tracking and analysis Education of the entire process
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13 Medical Student 13
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15 ISSUES IN THIS CASE Culture Organization Team Individual Work Environment Patient 15
16 AS BACKGROUND: JEHOVAH S WITNESSES AND REFERENCES TO BLOOD Genesis 9:4 "But flesh (meat) with...blood...ye shall not eat" Leviticus 17:12-14 "...No soul of you shall eat blood...whosoever eateth it shall be cut off" Acts 15:29 "That ye abstain...from blood..." Acts 21:25 "...Gentiles...keep themselves from things offered to idols and from blood..." 16
17 HUMAN FACTORS MODEL: CREDIT TO JOHN GOSBEE Psychomotor - Hand - Feet Senses - Vision - Hearing I N T E R F A C E Input Devices - Buttons - Foot pedal Output - CRT - Sound
18 IMPORTANT ISSUES The following note was written on Pt is a Jehovah s Witness and is not to receive PRBCs but is ok for plt and ffp per mother. This note is copied and pasted every day until Person who wrote the note admitted to being unaware of the content. Push button medicine? Legal implications 18
19 BLOOD CONSENT FORM 19
20 PATIENT FOLLOW-UP Team had a detailed family discussion and it was explained to them patient has critically low Hb [5 gms/dl] and due to patient being Jehovah's witness, lack of transfusion can endanger his life. Family understood the implications of not transfusing and made a decision to no transfuse him. He was also made DNR per family wishes. 20
21 HUMAN FACTORS: INFORMATION MANAGEMENT & COMMUNICATION n Copy and Paste in Medical record n Verbal orders n Inadequate hand-off and knowledge of critical information n Notification of blood bank of limited consent n Human factors related to signed consent n Consents in multiple areas of paper chart not in EMR as discrete documents until scanned after discharge n Consent design consent signature and refusal to consent on same page
22 HUMAN FACTORS: HUMAN RESOURCES INDIVIDUAL TASK PERFORMANCE n 41 hours of overtime in past time period n Policies and procedures not followed n Not patient-centered no notification of family prior to transfusion. n Cut and paste n Verbal orders
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25 REPORTING Reporting established as an expectation and part of Core Competency assessment
26 RESIDENT PHYSICIAN OCCURRENCE REPORTING DATA JOURNAL OF GRADUATE MEDICAL EDUCATION, JUNE 2010
27 EVENT DATA
28 ATTITUDE DATA: ATTITUDE IMPROVEMENTS [N = 50] I don t report because I am worried about discipline I don t report because I am worried about litigation I don t report because my colleagues may be unsupportive I don t report because I am uncertain which incidents to report Current systems for reporting patient safety problems are adequate Hospitals adequately support providers who experience stress
29 LESSONS LEARNED WE CANNOT FIX WHAT WE DO NOT KNOW ABOUT MEDICAL STUDENTS CAN GAIN KNOWLEDGE, SKILLS AND BEHAVIORAL COMPETENCIES IN PATIENT SAFETY AND HUMAN FACTOS SCIENCE THRU REPORTING INTO A ORGANIZATION S PATIENT SAFETY/OCCURRENCE SYSTEM AND ENGAGING IN FOLLOWUP INVESTIGATION AND PERFORMANCE IMPROVEMENT EFFORTS 29
30 QUESTIONS? 30
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Summary Thalassaemia is the most, chronic hemolytic anemia in Egypt the estimated incidence of thalassemia heterozygote s ranges between 5.6 to 9%. In recent studies over 1000 children affected with β-thalassemia
Preceptor Refresher Course
1 Preceptor Refresher Course How to Receive Your CE Credits Read your selected course Completed the quiz at the end of the course with a 70% or greater. Complete the evaluation for your selected course.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM TRASTUZUMAB (HERCEPTIN) Patient s first names.
Patient identifier/label: Page 1 of 6 PATIENT AGREEMENT TO SYSTEMIC THERAPY: CONSENT FORM TRASTUZUMAB (HERCEPTIN) Patient s surname/family name Patient s first names Date of birth Hospital Name: NHS number
Your Right To Make Your Own Health Care Decisions
Your Right To Make Your Own Health Care Decisions Sinai Hospital of Baltimore 2401 West Belvedere Avenue Baltimore, Maryland 21215-5271 WHAT YOU NEED TO KNOW ABOUT ADVANCE DIRECTIVES Sinai Hospital is
Michigan ADVANCE DIRECTIVE FOR MENTAL HEALTH CARE
Michigan ADVANCE DIRECTIVE FOR MENTAL HEALTH CARE I I,, am of sound mind and (Print or type your full name) voluntarily make this designation. APPOINTMENT OF PATIENT ADVOCATE I designate, my, (Insert name