Patient Safety & Risk Management - SD

Introduction

Hi, I am Dr. Christopher Merritt, professor of radiology at Thomas Jefferson University in Philadelphia.

The topic that will be discussed is that of performance improvement and risk management.

Many of the principles of risk management are generic in nature, but are important for anyone in the practice of medicine.

I'll review some of the issues that are of current interest in healthcare regarding to patient safety and practice improvement, as well as some specific topics related to ultrasound.

Patient safety and risk management are responsibilities of all healthcare providers.

And the following slides, I'd like to discuss some general concepts of patient safety and risk management and comment on some specific considerations for ultrasound.

The Significance of Patient Safety

The issue of patient safety has become one of the most significant challenges currently facing the American healthcare system.

The issue of patient safety is a high priority for the Department of Health and Human Services and its agency for healthcare Research and quality.

The AHRQ, many physicians are not aware of the significant of this issues.

Statistics on Medical Errors

For example, do you know how many deaths each year are thought to be due to medical errors in the United States?

Is it between 12,020 5,000, between 25 and 50,000, between 50 and a hundred thousand, or between 100 and 200,000?

In fact, the report of the Institute of Medicine suggested that medical errors result in between 50 and 100,000 deaths in the United States each year.

The Institute of Medicine report to Errors human indicated that 44,000 to 98,000 Americans die each year as a result of medical errors when this number is compared to the deaths from auto accidents in each year.

Do you think it's about one fifth, half, about the same, or approximately twice as many?

In fact, medical errors are thought to cause approximately twice as many deaths in the US each year as automobile accidents when compared to other causes of death, such as automobile accidents, which account for about 43,000 deaths each year, and workplace injuries about 6,000 each year.

The number of deaths attributable medical error is quite concerning.

These deaths exceed the number attributable to breast cancer in a typical department and a single 30 day period.

Types of Adverse Events and Medical Errors

The kinds of adverse events and medical errors that commonly occur include such things as failed notification of critical report values, delayed interpretation of studies, unclear communication of results, technical errors in performing the study and patient misidentification wrong procedure or wrong patient.

When considering these adverse events and errors, what percent of these are likely to be preventable?

25%, 50%, 75%, or 100%?

In fact, of the examples just given, essentially all were preventable and considering the issue of medical errors, two considerations deserve mention first are adverse events, which may or may not be preventable, and second are medical errors which are preventable.

Adverse events are injuries caused by medical management rather than the underlying disease or condition of the patient.

Some of these are not preventable.

For example, a life-threatening allergic reaction to a drug when the patient has no known allergies to the medication.

Others are preventable, such as administering a drug to a patient who's known to be allergic, resulting in anaphylactic shock and death.

Medical errors consists of failure to complete a planned action as intended, or the use of a wrong plan to achieve an aim.

And as such, most medical errors are preventable.

Diagnostic errors include misdiagnosis leading to an incorrect choice of therapy, failure to use an indicated diagnostic test, misinterpretation of test results, and failure to act on abnormal results.

Other types of errors may include equipment failure, infections, and misinterpretation of medical orders.

Preventability of Medical Errors

Research has shown that most medical errors can be prevented.

One review of over a thousand medical records shows that 70% of adverse events were preventable, 6% were potentially preventable, and only 24% were viewed as not being preventable.

Another study involving a review of 15,000 medical records found that over half of surgical errors were preventable.

Systems Approach to Reducing Errors

It's common for many physicians to view errors as the responsibility of individuals.

However, the Institute of Medicine is emphasized that most medical errors are systems related and are not attributable to individual negligence or misconduct.

The key therefore to reducing medical errors is to focus on improving the systems of delivering care and not to place blame on individuals.

Steps to avoid system errors include standardization of treatment policies and protocols to avoid confusion and reliance on memory, as this is known to be fallible and to be responsible for many errors in this setting, the National Quality Forum has devised 30 safe practices for better, better healthcare.

Many of these apply in the imaging environment.

The most important perhaps, is to create a healthcare culture of safety.

In this culture, we should encourage and support the reporting of any situation or circumstance that threatens or potentially threatens the safety of patients or caregivers.

And we should take the view that errors and adverse events are opportunities to make the healthcare system better rather than to place blame.

We should try to obtain the input from patients when they are given informed consent to be certain that they understand what they have been told.

We should implement standard protocols to prevent mislabeling of imaging studies.

We need to implement standardized protocols to prevent the occurrence of wrong site or wrong patient procedures.

We need to adhere to hand washing procedures prior to and immediately after contact with patients or objects immediately around the patient.

We need to focus on the importance of a team approach and system improvement with all of the members of the team Participating.

Emphasis should be on communication among team members and on the handoff procedures from one team to another.

Joint Commission National Patient Safety Goals

The Joint Commission for the Accreditation of Healthcare Organizations has established a number of national patient safety goals.

The purpose of the Joint Commission National Patient Safety Goals is to promote specific improvements in patient safety.

These goals highlight problematic areas in healthcare and describe evidence and expert based solutions to these problems.

The requirements focus on system-wide solutions wherever possible.

The Joint Commission is also identifying sentinel event alerts related to wrong site surgery, operative and postoperative complications, lookalike soundalike, drugs, medical gas, mixups, needle and sharps injuries, dangerous abbreviations, delays in treatment, nosocomial infections, medication reconciliation, and wrong root, wrong tube procedures.

Specific Practices for Reducing Errors

With the attention that medical errors are receiving at the regulatory level, we need to take serious thought regarding what we can do as practitioners to reduce medical errors.

Patient identification is certainly an issue that's relevant in imaging studies.

We need to be certain that we are accurate in the identification of our patients, and this requires the use of at least two patient identifiers when providing care, treatment, or services.

Invasive procedures require a timeout prior to the start of the procedure to verify that the correct patient, the correct procedure, and the correct site are identified prior to the procedure beginning.

In addition, this timeout should include active not passive communication techniques.

Communication of findings is extremely important for verbal or telephone orders or telephonic reporting of critical test results.

It's important to verify the complete order or test result by having the person receiving the information record and read back the complete order or test result.

If an individual cannot be reached, the interpreting physician should directly communicate the need for emergent care to the patient, the responsible guardian.

If possible, direct communication is accomplished in person or by telephone to the referring physician or an appropriate representative.

When test results reveal non-urgent findings, the interpreting physician should communicate the finding to the referring physician or other healthcare provider in a matter that reasonably ensures the receipt of the findings.

Another cause of concern that's reflected in the Joint Commission National Patient Safety goes is the standardization of abbreviations, acronyms, symbols, and dose designations that are used and prohibited throughout the organization.

The timeliness of reporting and receipt by responsible individual of critical test results also should be of concern and documented A standardized approach to the handoff communications, including the opportunity to ask and respond to questions about results should be implemented.

Hospital acquired infections are of great concern, and then any service that involves direct contact with patients compliance with the CDC hand hygiene guidelines becomes essential.

Another issue involves the involvement of patients in their care.

Patients should be encouraged to take an active role in their own care.

Providers should define and communicate the means for patients and their families to report concerns about safety and encourage them to do so.

These points about patient's safety and reduction of errors are important ones, but many physicians tend to focus primarily on the concern for medical legal issues.

Medical Legal Issues and Negligence

Medical negligence is defined by law, is established by showing that the physician has a duty which is recognized by the law, and that a breach of duty occurred as a result of a failure to meet what was considered to be the standard of care at the time the treatment was delivered.

Negligence can be established by showing that there was a causal relationship between the breach of care and the resulting EM injury and a loss or damage occurred to the injured party.

A number of organizations involved in ultrasound, including the A IUM, the American College of Radiology and the American College of Obstetrics and Gynecology have developed practice guidelines.

These do not define the legal standard of care in a given setting, but knowledge and adherence to these guidelines may be valuable in defense of a malpractice claim, good practice, as well as good defense against litigation.

That involves care to see that patient studies are properly identified, that the date and time are carefully and accurately recorded, that appropriate images are permanently retained, and that results are communicated in a prompt and efficient fashion examination should follow accepted protocols.

Many of these has been developed at a regional or national level by organizations such as the American Institute of Ultrasound and Medicine, the American College of Radiology, and the American College of Obstetrics and Gynecology.

Ultrasound-Specific Risk Management

As far as ultrasound is concerned, Roger Saunders has compiled over the years a list of common issues raised in malpractice, lawsuits involving ultrasound.

The most common is missing of a sonographic finding, particularly in obstetrical studies.

Others include misinterpretation of a, finding, the failure to compare current findings with previous results, failure to communicate in the report, The findings to the referring physician or the patient.

Failure to examine the patient or to take a proper history, use of an incorrect sonographic approach for a specific condition, performing an incomplete examination, generating images or films of inadequate quality and a variety of lesser issues which have appeared from time to time, including slip and fall injuries, complications from puncture techniques, failure to inform consent, complications of vaginal ultrasound such as bleeding or abortion equipment, problems, failure to recommend additional studies, failure to order an examination, inclusion of sonographers or ologists in shotgun lawsuits, loss of films or medical records, patient abuse and anxiety produced by misdiagnosis and other issues and closing.

Conclusion

Patient safety and risk management are determined by individual and system performance.

Efforts to improve patient safety and reduce medical errors involve the development of a culture of safety and the development of system approaches that reduce the potential for failure, particularly in the handoff of information from one caregiver to another.

The adopting of a culture of safety is essential.

This involves not hiding and denying bad events and bad consequences, but encouraging the reporting and analysis of any situation that threatens the safety of patients or caregivers, and using this information to review the systems and to correct and prevent these in the future.

Finally, the use of evidence-based approaches to practice taking advantage of national guidelines, standards, and appropriateness criteria is an important step in providing uniform quality care to all patients.