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Patient Safety and Medical Error
Holly J. Humphrey, MD
Dean for Medical Education
The University of Chicago Pritzker School of Medicine
The Institute of Medicine Quality Initiative
• To Err Is Human: Building a Safer Health System (Released November, 1999)
• Impact?– Awareness– Regulation– Reporting Systems– Information Technology
• Recognition that medical errors are not usually the fault of a single person but are usually the result of flawed systems (Leape, Berwick, JAMA, 2005).
The Physician Charter
Published by the ABIM Foundation, American College of Physiciansand European Federation of Internal Medicine in 2001. Ten professional commitments, including:
Commitment to honesty with patients “Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust.”
Commitment to improving quality of care“Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error.”
ABIMF, ACP, EFIM 2001
Barriers to Change• Threat to physician autonomy and
authority
• Fear of malpractice liability)
• Complexity of health system (mix of specialties, subspecialties, & allied health professionals, reimbursement issues)
• Lack of leadership
• Scarcity of measures to gauge progress
Leape, Berwick, JAMA, 2005
Intrinsic Challenge of Medical Education
Educational needs of
learners who require
increasing independence
Safety needs of patients who benefit when
being cared for by the most experienced
physician available
Ludmerer, Johns, JAMA, 2005
Patient Safety and Medical Education
PATIENTS
STUDENTS FACULTY
Interprofessional Teams Information Systems
Lifelong Learning
SYSTEMS
FOCUS
Humphrey, JGIM, 2005
Recent focus on “Hand-Offs”
• July 2003– ACGME set limits for resident duty hours– Reduce sleep deprivation and improve
patient safety
• Unintended consequence is increase in number of hand-offs
• Safety of hand-off– Error-prone – Variable– Vulnerable “gap” in patient care
Teaching “Hand-Offs” 90-minute interactive workshop on effective hand-off strategies
Objective Simulated Hand-Off Experience (OSHE) performed 7 days after initial workshop
Students evaluated pre- and post-intervention
Teaching “Hand-Offs”• Complete written sign-out
• Verbally “hand-off” patient and sign-out to standardized resident receiver
• Underwent one hour training on hand-off expectations using the case and anticipated trigger “interval” events
• Feedback facilitated using “Hand-off CEX”– Domains assessed were organization/efficiency,
communication skill, clinical judgment, professionalism
• Debriefing after OSHE
Teaching “Hand-Offs”Results:• Statistically significant improvement in preparedness for
performing effective hand-off – 12% pre vs. 50% post reporting “well-prepared” (p<0.012)
Student Comments:• Unanimously positive experience:
– “a must have, a great experience!” – “probably the MOST USEFUL of all topics, definitely under-
taught”
• Felt realistic due to actual resident evaluators • Wanted training for additional scenarios
– Practice “sending” and “receiving” hand-off
Conclusions
• Feasible interactive mechanism to provide students with ability to practice handoff communication
• Well-received by both students and resident receivers
• Has potential for future evaluative purposes