What can patients tell us about adverse events?

Report
Involving Patients and Families in
Patient Safety
III Simposio Internacional de Seguridad del Paciente
Centro Medico Imbanaco
16 de marco de 2012
Cali, Colombia
Saul N. Weingart, MD, PhD
Dana-Farber Cancer Institute and
Harvard Medical School
Boston, Massachusetts, USA
The patient safety epidemic
• 1999 Institute of
Medicine (IOM)
reports 44-98,000
excess deaths/year.
• Calls for research,
education, and
improvement.
3
Two views
Consumer patient safety
recommendations
• Learn to recognize liquid medications by
smell.
• Ask for a copy of your hospital MAR.
Check it for accuracy.
• Keep the lights on so you don’t
accidentally take the wrong drug.
• Keep people medicine separate from pet
medicine.
Objectives
• What is the patient’s experience
and understanding of medical
error?
• Can patients play a role in
identifying medical error and
preventing harm?
Conditions for patients to prevent
medical errors…
Ability to
behave
safely
Ability to
communicate
errors
Ability to identify errors
Can patients identify and
communicate
errors?
Inpatient adverse event reporting
study
Weingart et al. JGIM 2005; 20: 837-41
• Do you believe that there have been any
problems with your care during this
hospitalization?
• Do you believe that you were hurt or stayed in
the hospital longer than necessary because of
problems with your care?
• Do you believe that anyone made a mistake that
affected your care during this hospitalization?
Serious adverse event
“I had a PIC [percutaneous intravenous catheter]
line put in and I got an abscess. They took me
down to get surgery. I had a blood clot and they
removed part of my vein.”
Significant adverse event
“My blood sugar went sky high because they did
not give me my diabetes medication.”
Life-threatening near miss
“The doctor came in and suggested that I get a flu
shot. I am allergic to it. It would kill me. Do the
doctors not check patient charts?”
Adverse events
Serious
Significant
Minor
All AEs
Preventable AEs
Patients with
AEs, n (%)
1 (0.4%)
11 (4.8%)
5 (2.2%)
17 (7.4%)
12 (5.2%)
• Design
– Med/surg patients at 16 Massachusetts hospitals
• Sample
– 2,582 (62%) completed a post-discharge telephone
survey
– 998 also agreed to medical record review
• Analysis
– MD panel classified reports
What do patients know that hospitals
don’t? (n=998)
Patient
Reports
23%
Both Patient
Reports &
Chart Review
5%
Chart
Review
11%
Weissman, et al., Ann Intern Med. 2008; 149:100-108.
In sum, many patients can identify
and report “safety” events.
Some screening may be
necessary.
Behaving safely
Patients' Comfort Level in Performing
Error Prevention Behaviors
% Very
Error Prevention Behavior
N
Comfortable
Ask RN purpose of medication
948
91
Ask RN to confirm patient's ID
900
84
Have family/friend watch for
errors
966
76
Helping health care staff mark
surgical site
518
72
Ask medical personnel if they
washed their hands
924
46
Waterman et al. JGIM 2006; 21: 367-70.
Patients' Comfort Level in Performing
Error Prevention Behaviors
% Very
Error Prevention Behavior
N
Comfortable
% Who
Took Action
Ask RN purpose of medication
948
91
75
Ask RN to confirm patient's ID
900
84
38
Have family/friend watch for
errors
966
76
39
Helping health care staff mark
surgical site
518
72
17
Ask medical personnel if they
washed their hands
924
46
5
Waterman et al. JGIM 2006; 21: 367-70.
Factors that affect patient taking
action
•
•
•
•
•
•
Gravity of perceived threat
Preventability
Effectiveness of action
Consequences of speaking up
Self-efficacy
Staff members’ instructions and
expectations
How can we promote
engagement?
Medication Reconciliation
“Accurately and completely reconcile
medications across the continuum of
care”
TJC National Patient Safety Goal
Preliminary Findings
No. of patients
338
No. of drugs
2146
Corrected
102
5%
D/C’d drugs
510
24%
Missing drugs
585
27%
Total changes
1197
56%
Patient-Identified
Medication Updates
• Corrected
– Oxycontin
– Mycophenolate
mofetil
– Gabapentin
– Keppra
– Warfarin
• D/C’d
– Antibiotics (various)
– Antiemetics
• Missing
–
–
–
–
–
–
–
–
–
Heparin
Warfarin
Imatinib
Oxcarbazepine
Erlotinib
Testosterone
Dexamethasone
Thalidomide
Celecoxib
Medication Reconciliation Protocol
CAs
Prep
Charts
Collect &
Evaluate
Providers or Pharmacists
Update EMR
Patients
Update
Med Lists
CAs
Provide
Med Lists
Medication Reconciliation Monthly Totals
2500
2000
1500
Implement
Sustain
1000
Develop
500
'07
M
ar
M
ay
Ju
ly
'0
7
Se
pt
No
v
Ja
n
'08
M
ar
ch
Ja
n
No
v
Ju
l '0
6
Se
pt
ay
M
ar
M
'06
Ja
n
'0
5
0
No
v
Medication sheets reconciled
November 2005 - March 2008
Sheets reconciled
95% CI
Reconciled Medication Lists
Med List
Updates
Reconciliation Usual Care
N=42
N=47
P-value
Any
38 (90%)
1 (2%)
<0.001
Mean no. of
updates
(s.d.)
4.3 (4.1)
0.1 (0.4)
<0.001
A story
MRI OF THE BRAIN WITHOUT AND WITH CONTRAST
CLINICAL HISTORY: Headaches awakening the patient from sleep.
TECHNIQUE: Multiplanar pre- and post-contrast T1-weighted images, axial T2weighted, susceptibility and FLAIR images were obtained.
FINDINGS: There is an enhancing extra-axial mass at the anterior aspect of
the right middle cranial fossa, broadly contiguous with the greater wing of
the sphenoid bone and extending superiorly and projecting over the lesser wing
of the sphenoid bone. The mass measures approximately 3.5 cm in
anterior/posterior dimension by 4.5 cm in transverse dimension x as much as
4.4 cm in superior/inferior dimension. There is an enhancing dural tail and
the appearance of the mass is most consistent with a meningioma.
There is considerable right temporal edema and there is effacement of the
right temporal sulci and the right temporal horn. The right lateral ventricle
is smaller than the left and the septum pellucidum is shifted slightly towards
the left. Superiorly, the frontal and parietal sulci are also smaller on the
right than the left. There is some protrusion of the uncus medially and
indentation of the right mid-brain without tourqing of it.
No other masses are seen. The brain parenchyma is otherwise normal. The
paranasal sinuses are essentially clear with minimal soft tissue thickening
noted in the right maxillary sinus.
IMPRESSION: There is a 4.5 cm, intensely enhancing, extra-axial mass at the
anterior aspect of the right middle cranial fossa with an associated dural
tail most consistent with a meningioma. There is extensive edema in the right
temporal lobe, extending posteriorly and superiorly to involve the posterior
aspects of the internal and external capsules. There is diffuse asymmetry of
the right cerebral sulci and early right uncal herniation. The results were
e-mailed to Dr. ##### at approximately 9:30 p.m. on 3/13/03.
Teamwork training
Teamwork training
• Promising application
in ICU, OR, ER, L&D
• Key principles:
– Appropriate
assertiveness
– Briefing
– Close-loop
communication
– Situational awareness
“I lift, you grab. Was that concept just
a little too complex, Carl?”
Revised approach
• Campaign rather than education or
research
• Focus on hazards rather than skills
– Wrong chemo, last-minute change, hand
hygiene
• Bringing messages to the patient
• Empowerment without obligation
– “You CAN… check, ask, notify”
DANA-FARBER ADMITS DRUG OVERDOSE
CAUSED DEATH OF GLOBE COLUMNIST,
DAMAGE TO SECOND WOMAN
3/23/1995
When 39-year-old Betsy A. Lehman died suddenly last Dec. 3 at
Boston's Dana-Farber Cancer Institute, near the end of a grueling
three-month treatment for breast cancer, it seemed a tragic
reminder of the risks and limits of high-stakes cancer care. In fact,
it was something very different. The death of Lehman, a Boston
Globe health columnist, was due to a horrendous mistake: a
massive overdose of a powerful anticancer drug that ravaged her
heart, causing it to fail suddenly….
In 2012, we proudly celebrate
Adult Council for 14 years
Pediatric Council for 11 years
What can you do?
• Educate: brochures, posters, etc.
• Encourage patient reporting: problems,
errors, “negative events”
• Empower: Condition H
• Engage: medication reconciliation
• Use technology: portals
• Use teamwork tools
Questions…
• How much can (and should) we rely on patients
to ensure their own safe care?
• Does patient participation signal a failure of our
systems to prevent or trap errors?
• Can we customize the approach for different
patients with different capacities?
• What safety behaviors (for patients) hold the
most promise?
Hollywood ending
• 2002 national telephone survey of 1,207 patients
• 42% of patients reported medical errors in their
own or a family members’ care
Blendon et al. NEJM 2002; 347: 1933-40

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