DR. SAIRA ZAFARASSISSTANT PROFESSOR, DEPT OF MEDICINE

PROFESSIONAL DEVELOPMENTAL SERIES

FOR NEW PROFESSIONSL STAFF

FEB, 15TH 2013

LEADING QUALITY INITIATIVES

ObjectivesDefinition of Adverse Events ( AEs)Prevalence, types and causes of medical

errorsWhy should physicians be involved with

Quality improvement? My QI project journey

A story……………

Mrs. W is an 87 year old who was admitted to the CTU with pneumonia. She was treated with levofloxacin. Her past history was significant for CAD and atrial fibrillation for which she was taking metoprolol, warfarin and vasotec.

As she was confused, her medication list was determined by an older list her husband provided from their pharmacy. Included in that list was digoxin, a drug that was discontinued three months prior to the admission due to bradycardia.. The patient was on metoprolol 12.5 mg BID at home but it was ordered as 25 mg BID by mistake.

Due to increased dose of metoprolol and the inadvertently added digoxin, Mrs. W developed complete heart block from which she was successfully resuscitated.

Unfortunately the story is not over yet!

Story continues…………On day five …. She developed Upper GI bleed. At the time, her INR

was found to be 9 which was likely secondary to a drug-drug interaction between coumadin and the new antibiotic levofloxacin for which she was again appropriately treated.

On day 7 … She was found to have a creatinine of 200 mmol/L

and potassium of 5.4mmol/L. Despite this, her vasotec was not held and no repeat blood work was done until day 9 when she was found to have a creatinine of 650 mmol/L and potassium of 7.2mmol/L.

She subsequently had to undergo dialysis.

Definition

Adverse events are unintended injuries or complications resulting in death, disability or prolonged hospital stay that arise from health care management.

How common are medical errors

Institute of Medicine Land Mark Report:

At least 44,000-98,000 people die is hospitals each year as a result of medical errors in US

It was estimated that preventable medical errors in hospitals exceeds attributable deaths to AIDS, Breast cancer and Road Accidents.

17 billion to 29 billions dollars are spent each year due to medical errors.

To Err is Human: Building a Safer Health System: the National Academy of Science 2000.

How Common are the medical errors

Canadian Adverse Event Study showed that an estimated 7.5% of patients admitted to acute care hospitals in Canada experience 1 or more AEs. 36.9% of these patients were judged to have highly preventable AEs.

CMAJ May 25, 2004 vol. 170 no 11

How common are the medical errors

Analysis of Relative Risks and Levels of Risk in Canada, Ron Law Juderon associates

Why should physicians be involved with Quality Improvement

Various reasons:

Medico legal. We are ultimately responsible for our patients.

Ethical “Hippocrates oath” First do no harm PLUS SOME BONUS REASONS

Why Should Physicians be involved with quality improvement

Quality Improvement is a new field and has still a lot of potential for new professional staff to get involved and make a career.

Quality Improvement is relatively easier.No ethics approval requiredNot a lot of complex measurements and data

collection neededIts fun Results are immediate and rewarding

Types Of Medical ErrorsCommunication errors “ Team communication problems are the most frequently cited root

cause in JACHO sentinel event statistics”. “Sentinel events statistics, Sept 30, 2007,” Joint Commission on Accreditation of Healthcare Organizations

Within and between caregiver teams: Inadequate presentation and documentation of relevant findings and

plan Not communicating changing clinical status and/or care plans Miscommunication during transfers of care, sign out or discharge

With patient and family members: Inadequate patient education Not disclosing medical errors

Sutcliffe KM, Lewton E, Rosenthal MM. Communication Failures: An Insidious Contributor to Medical Mishaps. Acad Med. 2004;79:186-194.

Moore C, Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646-651

Types Of Medical Errors

Medication Errors:Faulty medication list and use historyErrors of ordering and prescribing ( wrong

dose, name, frequency)Poly-pharmacy and drug- drug interactionsErrors of drug monitoring

Forster AJ, Murff HJ, Peterson JF, et al. Adverse drug events occurring following hospital discharge. J Gen Intern Med. 2005;20:317-323.

Cornish PL, Knowles SR,et al. Unintended Medication Discrepancies at the Time of Hospital Admission. Arch Intern Med. 2005;165:424-429.

Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. JAMA. 1995;272:35–43.

Types Of Medical Errors

Cognitive Errors:

Wrong or delayed diagnosis Not ordering the indicated tests Failure to employ right treatment Error in performing a procedure or operation

Follow up and monitoring errors:

Inadequate monitoring of disease activity Inadequate follow up on test results and

Situational factors such as stress, fatigue and work load may all serve to increase these errors

Many errors do not occur in isolation, those with significant impact on outcomes often occur in series

Interventions shown in literature to reduce errorsAvoidance of reliance on memory Checklists Computerized physician order entry (CPOE) with decision

support capabilities greatly enhance the safety of prescribing.

Simplify and standardize the process: Surgical time out Standardize transfer of care/patient discharge process/sign-outArora V, A model for building a standardized hand- off protocol. Jt Comm J Qual patient saf.

2006;32(11):646-55

Encourage error reporting and near-misses, and use them as opportunities to prevent future errors

Example of My Own QI project

MY own QI projectI conducted a hand hygiene initiative for

medical students and residents rotating through three clinical teaching units at University Hospital.

Compliance rate was very poor, around 45%, and various methods such as education and reminders were not doing anything.

I introduced a competition between three CTU teams with a prize for the winning team on monthly basis.

I used Institute of health care improvement “model for change”

Institute for healthcare improvement

“Model for change”

Langley GL, Nolan KM, The improvement guide: A practical approach to enhancing organizational performance. 2009.

The Results

Within a month compliance increased to 85% and is still maintained after a year.

I got promoted, but most importantly, it was so much fun doing the project!

Now I am involved with various other projects such as reducing readmission rates for CHF patients, hand hygiene initiative on broader scale etc.

Resources for Quality Improvement

www.IHI.org

QUESTIONS?