Week 12 - Safety in Clinical Settings

Prevent Medication Errors

5 Rights of Medication Administration - Right *medication* - Right *patient* - Right *dosage* - Right *route* - Right *time* (frequency)

Discussion and Planning for disclosing a medical error

A team needs to: - Understand institutional requirements for conduct of the disclosure - Agree on who will be involved in the disclosure - Agree on what will be said - Agree on how each team member's role will be represented - Know what to expect from the patient and family

Preventable Adverse Event (defined)

An adverse event injury that could have been avoided as a result of an error or system designed flaw Ex. Bed check for patients with unsteady gait

Adverse Event (defined)

An injury caused by medical management rather than by the underlying disease or condition of the patient

Ameliorable Adverse Event (defined)

An injury whose severity could have been substantially reduced if different actions or procedures had been performed or followed Ex. Did not provide early Abx for sepsis points

Airborne Precaution

Ex: Mycobacterium tuberculosis (TB); measles; chicken pox and herpes zoster (until lesions are crusted over) - Room requires negative pressure - Wear N95 respirator - Patient to wear surgical mask during transport

Exposure Protocol

Exposure - Sharps injury contaminated with blood and/or body fluid - Splash to eyes, nose or mouth - Blood or bloody fluid exposure to non-intact skin *Protocol varies by facility, but generally* - Wash area with soap and water - Use eye splash station - Notify supervisor, go to ER or employee health ASAP (don't wait for end of shift) - Get name of patient - Patient will be test for: HIV, Hep B, Hep C

Who should be told?

Facts - generally the sooner the better - Avoid natural desire to "put it all together"

Universal Precaution Handwashing & PPE

Hand Hygiene - *The single most important thing you can do to prevent infections* - Alcohol based, soap and water - Clean hands --> Before entering or leaving patient's room --> Touching anything contaminated --> Before putting on or after removing gowns *Should use Soap and water (not alcohol sanitizer) if:* - if hand is visibly soiled - caring for patient with known or suspected C. Difficile, MSRA, VRE

Error of Omission (defined)

Occurs when a necessary procedure or intervention failed to be performed - leading to morbidity or mortality to the patient involved Ex. Patient with fever, cough - failed to order X-RAy; patient later found to have severe sepsis from PNA, now intubated due to respiratory distress

Emotion Handling

Patients and clinicians may both undergo: - Anger - Sadness - Fear - Uncertainty

"Second Victim" 2 of 2

Seek support, take time to heal - Risk managers and critical incident teams - Support groups - Your physician supervisor - Your PA colleagues - Other healthcare provider colleagues - Personal counseling Become advocate for others

Negligence (defined)

Whether the care provided failed to meet the standard of care reasonably expected of an average physician qualified to take care of the patient in question

Employee Health Issues

You should not go to work if you have an infectious disease that may spread to employees, patients and visitors Example: - Infectious diarrhea (gastroenteritis) - Fever (fever & cough or sore throat during flu season) - Rash - due to chicken pox, herpes zoster, scabies *Note:* you may be require to be cleared by Employee Health before resuming work

AAPA Stance of Medical Errors

"A physician assistant should disclose to his or her supervising physician information about errors made in the course of caring for a patient. The supervising physician and PA should disclose the error to the patient if such information is significant to the patient's interests and wellbeing. Errors do not always constitute improper, negligent, or unethical behavior, but failure to disclose them may."

Medical Errors Defined

"An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim" Institute of Medicine "An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems." Quality Interagency Coordination Task Force (QuIC)

Understanding the Apology

"I'm sorry for what has happened to you" --> Always appropriate Do not blame "the system" or colleagues --> "hospitals are complicated places..." --> "I'm sorry, if the nurse had only called me..." Be careful of apologies that include "BUTS" --> "I know this is unpleasant, awful...BUT believe me, for me its shattering"

Strategies to prevent medical errors cont.

*Collaborate to reduce infections* - Form committees - Remind employees of the importance of these strategies (measures) - Advertise on hospital websites, paychecks, signs in hospitals, etc. *Avoid diagnostic errors* - Incorporate the entire team (physicians, radiologists, etc) - Utilize expertise and skills effectively *Utilize Electronic Health Record* - Not an issue anymore

"Second Victim" (as the provider) 1 of 2

*Controversial Term* *Reaction has been liked to an acute stress disorder* - Embarrassment - Denial and detachment - Loss of confidence - Inappropriately adjusting practice - Emotional and physical health: depression, anxiety, re-experiencing the event, substance abuse

Strategies to prevent medical errors

*Hand-off communication* - PA to PA sign-out - PA to RN, Physician communication - HOC section in EHR Involve multidisciplinary team and utilize team building skills --> involve pharmacist during rounds

What Comes Next? (with patients

*Patient and patient's/family's response* --> Disclosure skills/techniques are key *Legal Institutional retaliation* --> Working with your institution --> Malpractice concerns *Professional concerns* --> Colleagues will lose trust --> Patients will lose trust

Discussion and Planning for disclosing a medical error Patients/providers

*Patients will need:* - Emotional support and acceptance - Truthful information in a timely fashion - To understand that multiple discussions may be required to address all questions - Medical information in appropriate, but jargon free language - To understand what happens next *Providers will need:* - Disclosure coaching - To be informational, instrumental and give emotional support

Medical Errors

- *THIRD* leading cause of death in the US - 10% of US deaths are now due to medical errors - Medical errors are under-recognized cause of death --> unintentionally excluded from the national health statistics --> no ICD codes assigned

Medication Errors

- Account for a majority of medical errors - On average four out of five US adults will use prescription medicines, over-the-counter drugs, or dietary and herbal supplements - About 1/3 of adults take five or more different medications -Given these statistics - the need to focus on medication errors is crucial

Be prepared for compensation questions

- Acknowledge that the question is legitimate - Explain that you are not qualified or authorized to address those issues - Assure them that others who are qualified will speak with them in the near future

Key Points for Clinical Phase

- Clinical phase is very exciting but could be dangerous - Get your immunization - Educate yourself about safety concerns & be vigilant about your own safety - PA students must be aware of their own limitations and lack of experience, especially when volunteering to learn a new skill - Review facility policies and have emergency contact information with you at all times

Some causes of Preventable Medical Errors

- Communication (i.e. illegible handwriting, language barriers, inaccurate documentation, poor team work) - Medication - Misdiagnosis - Under or over treatment - Surgical errors - Lack of education or experience - Incompetent staff - Clinician burnout (fatigue)

What type of Adverse Event is the following? Patient admitted with chest pain, EKG showed STEMI; patient not taken to cath lab immediately and eventually dies

- Error of Omission - Considered negligent

Steps In Disclosing Error: A Process

- Explain that an error occurred - Apologize and express regret for the error - Convey the underlying elements resulting in the error - Address medical ramifications and how the error will be managed - Described steps that will be taken to prevent the recurrence of the error - Arrange to speak again at a time that is convenient to patient and family - Talk about follow-up

What to do if you make an error?

- Follow your institution policy - Be honest and disclose to your supervisor and supervising physician - Discuss as a team how to proceed - Also disclose to the patient

Preparation: Advice for Clinicians

- Get help, prepare and discuss as a team --> most failed disclosures is caused by lack of preparation - Attend to the patient's medical needs - Initial discussion within a few hours of the event - Who will be in the room? --> clinicians with prior relationship --> ensure everyone is emotionally capable --> Careful planning of roles during discussion

Influenza Prevention

- Get vaccinated - If not vaccinated - wear mask at all times - Identify patients with symptoms of influenza early: --> Fever, cough, sore throat --> Test for influenza --> Droplet precaution - Other disease requiring droplet precaution: --> Neiserria meningitidis & H. Flu meningitidis --> pertussis (whooping cough) --> other respiratory virus (ie. Adenovirus, RSVmm parainfluenza)

PA Student Safety in Clinical Settings

- Immunizations (Hepatitis B, MMR, Influenza) - TB Testing (PPD, Quantiferon) - Ask your preceptors about safety policies --> What to do if you sustain an injury --> Requirements for male and female exams (chaperones) --> What to do in an emergency --> Who have access to clinical spaces

Universal Precautions

- Infection control guidelines designed to protect health care providers from exposure to diseases spread by blood and certain body fluids - Students must assume everyone may be able to transmit potential infectious diseases - Use of Personal Protective Equipment (PPE) such as gloves, gowns, masks, protective eyeware

Patient Safety

- Many adverse events are neither preventable nor ameliorable Ex. Patient received appropriate treatment with Abx for the first time - developed allergic reaction (this is an unavoidable adverse event)

Needlestick and Sharps Injury

- Most common efficient method of transmitting blood-borne pathogens between patients and clinicians - CDC estimates approximately 385,000 sharps-related injuries each year in hospital settings - Sharps injuries are primarily associated with Hep B virus (HBV), Hep C virus (HCV), & human immunodeficiency virus (HIV) --> but they have been implicated in the transmission of more than 20 other pathogens - PA students are at high risk due to inexperience

Universal Precautions for EBOLA

- Must received comprehensive training on Ebola-related infection control practice & procedures - PPE must covers entire body - Supervised by onsite Manager - Every step of the process is supervised by a trained observer - Individuals unable or unwilling to adhere to infection control and PPE use procedures should not provide care for patients with Ebola

Contact Precaution

- Patients in room by themselves (isolated) or with another patient with same organism *EX:* MSRA, VRE, C.Diff, Scabies, generalized rash (C. Difficile spores can live in the environment for as long as 5 months) - Wear gown and gloves before entering room and remove before leaving room - Wash hands with soap and water - Sanitize any equipment used (including your stethoscope)

What type of Adverse Event is the following? Patient had wrong limb amputated.

- Preventable adverse event

What type of Adverse Event is the following? Patient with known allergy to specific meds, receive the med and develop reaction.

- Preventable adverse event - Considered negligent

Student Mistreatment

- Verbal - Sexual - Physical - Gender-Based - Race-Oriented - Religious-Based

Prevent Medication Errors (examples)

- Verify patient's medication - from patient, pharmacies, other clinicians, family members - Medication Reconciliation - Clear and detailed documentation - Use weight based dosage - especially for kids - Be familiar with your institution's medication administration policies, regulations and guidelines - Have a drug guide available (PDR or electronic format - Epocrates) - Utilize pharmacists - Use appropriate patient identifiers - Verify allergies and reactions