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Prevention of Medical Errors FS 456.013(7)
Presented byDebra Davidson, MJ, ARM, CPHRM
Patient Safety Department
A Risk Management Seminar for Physicians
Indiana Osteopathic Association December 8, 2012
2
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.
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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
• 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
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1. IOM2. FHA/ASHRM 3. JAMA (10/2006)4. PIAA Newsbriefs 10.16.20065. 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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R isk Po in ts
3 . _______
2 .________
1 .________
C orrec t iveM easures
C linical
P rocesses
3 . _______
2 . _______
1 . _______
C orrect ive M easu res
O rgan iza tional
S ys tem s
C ausa l Fac to rs
1 . T ype o f E rror
___________
___________
___________
___________
___________
___________
2 .
___________ ___________
3 .
M ED IC AL ER R O R
Implementation
1. _______
2. _______
3. _______
Measurement of Effectiveness
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Root Cause Analysis (continued)
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Root Causes—Medical Errors
• 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)*
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
• 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
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.
Prevention of Medical Errors /The New Yorker
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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
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www.npsf.org
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Clinician/Clinician Communications
• Referrals• Diagnosticians• Surgical clearance• Hospitalists• Hospitalization• Handoff: SBAR Report
Situation Background Assessment Response
Prevention of Medical Errors /CHAIN OF COMMAND
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Smart phones
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Communication Error Prevention
• Patient-centric culture• Awareness• Team building • Training• Protocols–checklists
• Eye contact• Slow down• Listen• Language• Visual aids• Limit and repeat• Ask Me 3• Verify with teach back
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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• Cancer• Cardiac• Neurologic condition• Acute abdomen• Complications–Pregnancy• Addiction, psychiatric conditions and diversion
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Frequently a concurrent condition
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Missed Diagnosis Root Causes
• Personal bias
• Haste
• Misguided axioms
• Poor history
• Inadequate exam
• Failed evaluation and pursuit
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• Inadequate follow-up system
• Failure to define parameters
• Inadequate assignment of care management
• Faulty communication of clinical concerns
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Missed Diagnosis: Cancer
• Most prevalent missed diagnosed condition 60%–Serious injury1
30%–Death1 50%–PCP1
2/3–Cancer1 30%–two or more clinicians
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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
Prevention of Medical Errors /PIAA AMI Study
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Missed Diagnosis: Neurologic Condition (continued)
• Diagnostic testing 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
• Appendicitis • Esophageal varices• Abdominal aortic aneurysm• Peptic ulcer disease• Hernia of abdominal wall• Cholecystitis/lithiasis• Ectopic Pregnancy• Diverticulosis• GERD
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PIAA Data Sharing System Report 1985-2007
Encountered in 5-10% of all ER visits
• Renal stones• SBO• Hiatal hernia• PID• Pancreatitis• Colitis• IBS• Gastroenteritis
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Missed Diagnosis: Pregnancy and Its Complications
• Failure to diagnose Ectopic Pregnancy Gestational Diabetes Pre-Eclampsia/Eclampsia
• Failure to diagnose pregnancy prior to treatment Routine radiology Invasive diagnostics Medications deemed high-risk for pregnancy Other pertinent treatment initiatives
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Diagnostic Error Prevention
• Triage–H&P · • Evaluate and document signs and symptoms• Diagnostic pursuit–index of suspicion• Define parameters• Referral and follow-up ·• Clarify responsibilities • Manage non-compliance• Monitor follow-up appointments
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Diagnostic Error Prevention (continued)
• Childbearing–testing • Communicate and document plan
Education Diagnostics Treatment Follow-up
• Diagnostics Physician review Communicate Tracking/Recall
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Diagnostic Error Prevention (continued)
• Tracking and recall systems 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
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Archives of Internal Medicine. 2009;169(17):1578-1586.
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Data Pending
SPECIMENS Pap C&S Biopsy
RADIOLOGY Chest X-ray MMG DEXA US
___ CT/MRI____
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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
Referral Notes/Records________ Referrals________ Records
Patient: Date: ___ ____
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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
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Joint Commission on Accreditation of Healthcare Organizations
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Wrong Surgery Root Causes
• 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:
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
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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) Letter of Concern $5,000 fine Costs of investigation and processing (@$2,500) Five CME’s Risk Management One hour lecture–develop and deliver
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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.
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West Boca High cheerleader got fraction of drug needed, lawyer charges
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Surgical Error Prevention
• Identification• Technology–bar-coding/photo ID• Verification protocol • Mark site • Patient education and preparation• Consent/Education• Prophylactic ATB• Protocols• Training
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Surgical Error Prevention (continued)
• 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
• 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
• Insulin• Albuterol• Morphine• Heparin• Cefazolin• Warfarin
Prevention of Medical Errors /MEDMARX/USP Drug Safety Review
• Furosemide• Levofloxacin• Vancomycin• KCI (potassium chloride)• Curare-type paralytics
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Medication Error Root Causes
• 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•
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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 otherPeriod 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 formultiple drugs
Write drug names in full
Apothecary units Unfamiliar to manypractitioners. Confused with metric units.
Use metric units
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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) whenpoorly written
Write "ml" or “milliliters”
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LASA Medications
• 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)
Prevention of Medical Errors /JACHO 2005 National Patient SafetyPA-PSRS Patient Safety Advisory
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LASA Medications
• 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
Prevention of Medical Errors /JACHO 2005 National Patient SafetyPA-PSRS Patient Safety Advisory
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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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Zyrtec vs Zyprexa
LASA Medications
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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
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Medication Error Prevention
• 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
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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
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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
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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
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MEDICATIONS Patient:______________________________________DOB: ______________________ Allergies: _______________________________________________________________ Date Medication Dose Frequency Samples Pharmacy Refill/MD Refill/MD Refill/MD Refill/MD
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ANTICOAGULANT THERAPY
PATIENT:_____________________________________________________________
DATE PT INR DOSAGE INSTRUCTIONS INITIALS
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Patient Safety Guidelines and Safety Systems
• 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
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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.
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Disclosing Medical Error (continued)
• Seek legal/risk management guidance• Communicate• Express concern/empathy• Do not blame• Present a plan• Confirm understanding• Document
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Documentation
• 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
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Documentation (continued)
• 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
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Click to edit Master title style
Click to edit Master text styles Second level
Third level
– Fourth level» Fifth level
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“The pessimist complains about the wind;
the optimist expects it to change; the realist adjusts the sails.”
--William Arthur Ward
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Your Role in Reducing Medical Error
• Establish culture• Promote effective team functioning• Anticipate the unexpected• Create an environment of trust and cooperation
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Mission Statement
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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[email protected](800) 421-2368, ext. 4005