Attending Version
Patient Safety and Handoff Module
created by Dr. Fraz Harji
Objectives:
By the end of this module you should be able to:
1. Define medical error.
2. Recognize the incidence and economical impact of medical error.
3. Identify 10 contributors to medical error.
4. Name general principles that should be applied to improve patient hand-off/ Sign-out
References:
1. Institute of Medicine (IOM), To Err Is Human: Building a Safer Heath System, 1999.
2. Redelmeier, D. A. MD, The Cognitive Psychology of Missed Diagnoses. Ann Intern Med. 2005; 142: 115-120.
3. Arora, V., Johnson, J., Lovinger, D., Humphrey, H.J., and Meltzer, D.O., Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual. Saf. Health Care 2005; 14, 401-407.
4. What does JCAHO expect for handoffs? OR Manager, April 2006.
MISTAKES ARE INEVITABLE
“Safety does not reside in a person, device or department, but emerges from the interactions of components of a system.” (IOM)
1. How many people die in hospitals each year as result of medical errors?
- Institute of Medicine (IOM) 1999 report indicated that as many as 44,000 to 98,000 people die in hospitals each year as the result of medical errors.
- Error defined as “an unintended act (either of omission or commission) or one that does not achieve its intended outcome.”
2. Do medical errors kill more or less people than…breast cancer, AIDS, or motor vehicle accidents?
- Using lower estimates, this would make medical errors the 8th leading cause of death in this country – higher than motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516).
3. How many people die from medication errors alone?
- About 7,000 people/year are estimated to die from medication errors alone (in or out of the hospital)
4. What is the total economic cost of medical errors?
- Total national costs (lost income, lost household production, disability and health care costs) of preventable adverse events (medical errors resulting in injury) are estimated to be between $17 billion and $29 billion, of which health care costs represent over one-half.
5. What contributes to medical error?
· Medication error
· Equipment failure or misuse
· Post procedural complication
· Miscommunications
· Wrong patient
· Wrong side of body
· Poor/illegible handwriting
· Incompetence
· Lack of experience
· Judgment errors
· Time pressures
· Distracted or rushed providers
· Inadequate supervision
· Diagnostic/therapeutic error
· Increase in technology
· Changes in staffing
6. In any industry, one of the greatest contributors to accidents is what?
- Human error; it is estimated that, on average, 60–80 percent of accidents involve human error.
7. What to do when a mistake happens?
- Address the problem and the emotional consequences
- Identify ways to prevent errors in the future
v Failures in communication between healthcare personnel account for majority of the adverse events/errors; It is especially vulnerable to error during times of transition or a patient “hand-off” or “sign-out”.
General Principles of Improved Patient Hand-off/ Sign-out:
· Accurate
- Accurate information is provided on the check out sheet which should include patient name, medical record number, room number, drug/food allergies, code status, age, primary admission diagnosis, any other complicating factors or other active medical problems, current medications especially for the active problems.
· Updated
- Information on the check out sheet is updated just prior to sign-out - this includes if any studies or consults are pending for the day, anything to follow up on, such as labs, studies…etc
· Pertinent
- Information on the sheet should contain any contact/family phone numbers, guardian number for those without decisional capacity – and this needs to be stated so that they cannot sign out AMA or be consented for procedures.
· Legible
- Hopefully this is solved by typing out the check out sheet
· Thorough
- Thorough information includes for example what medication was increased earlier that day for blood pressure, which would help guide the next move, i.e. either increase same medication further or stay at same dose and wait for steady state, or add another medication.
· Face to face
- Face to face communication reduces error and includes going through each patient and providing brief summary, this is especially important in emphasizing the critically ill patients.
· Anticipate
- Anticipate patient needs and provide suggestions to help cross cover on patients including need for pain control, blood pressure parameters, medication suggestions, any previous adverse events to any particular medication, sun-downing behaviors, sleep aids, etc.
Case:
HPI: 62 yow with history of DM, HTN, hyperlipidemia, recently discharged from hospital one week ago for hemorrhagic stroke. Patient was transferred to skilled nursing facility for rehabilitation. Patient is aphasic which resulted from the recent stroke. She is unable to provide any information. Patient’s family is available with limited history. On the transfer sheet and per the ER, patient returned to the hospital for vomiting several episodes earlier in the day, which was describes as dark stuff.
PMH:
1. DM
2. Hyperlipidemia
3. Hypertension
4. Recent hemorrhagic stroke
Medications at nursing home:
1. Lantus 30 units SQ qhs
2. Sliding scale insulin as needed
3. Atorvastatin 20mg qd
4. Metoprolol 100mg bid
5. Diltiazem 90mg qid
6. Clonidine 0.6mg qid
7. Hydralazine 75mg tid
8. Lisinopril 40mg qd
9. Aspirin 81mg qd
10. MVI qd
Allergies: NKDA
SH and FH: not able to obtain secondary to aphasia
PE:
Temp 36.7, hr 80, rr 16, bp 160/105, O2 sat 95% RA
Gen: NAD, appears comfortable
HEENT: unremarkable
CV: RRR w/o m/g/r
Lungs: clear bilaterally
Abd: soft, nd, positive bowel sounds
Extremities: no edema, warm, 2+ pulses
Neuro: weakness of R side of body, spontaneously moves left side, can follow simple commands intermittently
Labs: h/h 12/36 (previous hct from recent admission 37); chemistries: normal
NG lavage reveals coffee ground material, but no signs of active bleeding.
A/P: Patient is admitted to the hospital to the Medicine service with GI consultation. Patient is made NPO, except medications, and started on fluids, PPI and the rest of the medications from the nursing home. Over the next 24 hours, patient does well and no further episodes of vomiting or bleeding is documented, and hematocrit remains stable. You are now called by the floor nurse urgently that the patient has a heart rate of 40 and blood pressure of 80/40. What went wrong?
Answer: considerations should include whether the correct medications were administered to the patient, correct dosages, which medications, how long ago was the last dosages of medications which could cause bradycardia, are they long acting/short acting, how were the medications verified to be the right ones patient was taking at the nursing facility, and ultimately, were these dosages and types of antihypertensives the ones prescribed upon discharge one week ago, are there any new medications added recently at the nursing facility, does the patient have hemodynamic instability not related to medication error/adverse effect…ie cardiac conduction abnormality, MI, etc.
Review Questions:
1. 60 yo woman with history of hypertension, CAD, and hyperlipidemia is admitted to the hospital for atrial fibrillation with rapid ventricular rate last night to another team. You, as an intern/resident are called as cross-cover to evaluate this patient for heart rates in 30’s. What is your next step in the management of this patient?
a. Instruct the nurse to start pacing the patient.
b. Go to bedside to evaluate the patient.
c. Instruct the nurse to give epinephrine.
d. Instruct the nurse to give atropine.
e. Tell the nurse not to worry, since we are attempting in controlling this patient’s heart rate.
Answer: b
2. 56 yo man with history of DM, hypertension, CAD is admitted for Acute MI. In the Emergency Department patient receives the usual cocktail of medications and you are called to admit this patient. A few hours later, you are called by the floor nurse that patient is having trouble breathing. You arrive at bedside and note that patient cannot speak very well and drooling. You proceed to intubate the patient and airway was difficult to obtain. You then call the MICU resident, but they are busy with another crashing patient. You then help out with transfer orders and copy your previous orders. What is your next step?
a. Place the care of this patient to the MICU team.
b. Obtain a chest x-ray.
c. Obtain an ABG.
d. Review the ER log.
e. Start patient’s home medications.
Answer: d (patient received ace-I in the ER and had a reaction)
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to Dr. Wendy Gerstein, Department of Medicine, VAMC (111).
1) Topic of module:______
2) On a scale of 1-5, how effective was this module for learning this topic? ______
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment below:
______
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient curriculum in general:
6) Please circle one:
Attending Resident (R2/R3) Intern Medical student