PREVENTING MEDICAL ERRORS: PART 2
Gloria Coronel-Couto, MD, Assistant Professor of Medicine, University of Miami Miller School Medicine
| Example of lack of communication: regular patient with chronic obstructive pulmonary disease (COPD) calls
for appointment, speaks to nurse who takes his primary complaint; patient sees physician for what he describes
as shortness of breath
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 | Physician: Okay, Mr Garcia, what sort of trouble have you been having?
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| Patient: Well, I’ve had some trouble with my legs and
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| Physician (interrupting): Have you had trouble breathing?
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| Patient: Well, yes. I have trouble breathing. You know, I have emphysema and .
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| Physician (interrupting): Are you coughing? Coughing anything up?
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| Patient: No, not really. It’s just
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| Physician: So, do you have chest pain, fever?
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| Patient: No, no chest pain, no fever
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| Physician: What medications are you taking?
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| Results: both physician and patient unhappy with this conversation; as patient’s symptoms grew worse, he went to
emergency department where he was diagnosed and treated for deep venous thrombosis (DVT) and pulmonary
embolism
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| Take home points on communication
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| Listening requires paying attention to patient’s complaint in its entirety: do not assume patient with chronic disease
coming in for same complaint; do not rely on what nurse says about patient’s complaint
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| Avoid leading questions: eg, “so you’re here for your blood pressure medication?”; instead say, “what brings you
here today?”
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| Have no preconceived notion as to what is wrong: take time for differential diagnosis
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| Check to make sure you interpret correctly what patient tells you
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| Do not give in to time pressures: if necessary, schedule another appointment
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| Another case of miscommunication: patient with mild renal insufficiency complains of abdominal pain; you
write order for computed tomography (CT) of abdomen without contrast (CT Abd w/o contrast); radiology department
misreads order as “with contrast” (ie, w/o as w/c); patient gets contrast without postprocedure hydration,
leading to worsening of renal failure
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| Errors include:
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| Use of initials and abbreviations
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| Radiology department did not confirm order
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| Diagnosis of chronic renal failure not included in order
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| Patient did not know what procedure to expect: should have been told, “they will give you something to drink;
they should not inject anything in your veins”
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| Another communication problem: 60-yr-old woman with type 2 diabetes has difficulty controlling glucose;
needs change in prescription
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| Communication gap
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| Patient currently receiving: metformin 500 mg qid and glyburide 10 mg bid; hemoglobin (Hb)A1c ≈9% (should
be <7%)
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| Patient verbally instructed to: discontinue metformin and change to Glucophage XR 2000 mg per day; stop glyburide
and start NPH insulin before dinner
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| Physician reconsiders: instructs patient to take NPH insulin only at bedtime; arranges for nurse to instruct patient
on injecting insulin and to schedule follow-up appointment in 2 wk
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| Two days later: patient admitted to hospital with severe hypoglycemia; patient confused, took Glucophage XR
and metformin, and injected NPH insulin before dinner and at bedtime
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| Provide patient with written directions: allows patient to refer later to paper with directions
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| Tell patients: “it’s okay to ask”; “know your medications”; “no news” is not “good news” (always notify patients of
test results)
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| Communication after hospitalization: study found 50% of patients discharged with laboratory results pending
(unclear who follows up); 9% of results considered actionable (eg, antibiotic change); many physicians unaware of
test ordered by another physician (team member)
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| Potential benefits of national electronic medical record: physician with easy access to medical record more
likely to review contents; would dramatically improve communication among inpatient, outpatient, referral, laboratory,
and diagnostic centers; would provide reminder systems, disease registries, and clinical data to track performance
(eg, would have enabled physicians to quickly identify and notify patients taking rofecoxib [Vioxx] when
drug withdrawn from market); huge expense major drawback
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| Failures of system responsible for medical errors: we need to identify and analyze adverse events
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| Errors of commission: action clearly wrong
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| Errors of omission: failure to take clearly correct action
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| Near-miss: error narrowly avoided
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| Do not point fingers at: nurse or physician caring for patient when error occurred (eg, patient develops acute respiratory
distress syndrome); responsibility lies with all who had contact with patient, eg, possible failure to keep
head of bed elevated 30° or to monitor for infection; do not blame individual, just fix system
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| Near-misses: offer opportunity to fix system before patient harmed or before another near-miss occurs
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| Definition of system: set of interdependent parts that share common aim; parts need to work together like football
team, with little variability; all components of system influence each other
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| Where we are in meeting goal: 1999 Institute of Medicine (IOM) report called for decreasing number of preventable
deaths by 50% in 5 yr; while not near meeting goal, organizations currently looking for ways to increase
progress toward goal
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| Leapfrog Group: represents large health care purchasers
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| Advocate “safety leaps”:
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| Computerized physician order entry (CPOE)
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| Staffing intensive care unit (ICU) with intensivists (not general internists)
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| Making public results of performance measurement programs
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| Providing consumers with information on rating of hospital quality (available by zip code at www.leapfroggroup.org)
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| Referring patients to hospital that performs high volume of complex surgical procedures and has low rate of
complications
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| Joint Commission on Accreditation of Healthcare Organizations (JCAHO): emphasizes evidence-based
medicine; “core measure sets” based on proven methods of improving outcome (eg, whether patient treated for
myocardial infarction [MI] got aspirin, β-blocker, or angiotensin-converting enzyme [ACE] inhibitor; how long
it took patient with pneumonia to get antibiotic); JCAHO current focus on acute MI, congestive heart failure, and
community-acquired pneumonia
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| Heart attack care: ACE inhibitor for left ventricular systolic dysfunction; smoking cessation counseling; aspirin on
arrival; aspirin at discharge; β-blocker on arrival; β-blocker at discharge; percutaneous transluminal coronary angioplasty
(PTCA) received within 120 min of arrival; thrombolytic agent within 30 min of arrival; institution’s
inpatient mortality for acute MI
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| Heart failure care: ACE inhibitor or angiotensin receptor blocker (ARB); smoking cessation counseling; discharge
instructions (advice on diet); echocardiography
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| Pneumonia: smoking cessation; antibiotic counseling; blood cultures before antibiotics; initial antibiotic received
within ≤8 hr (preferably ≤4 hr) of arrival; correct antibiotic given; influenza and pneumococcal vaccination; oxygen
assessment (blood gas)
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| JCAHO National Patient Safety Goals: highlight problems in health care; provide expert-based solutions to
problems; report “sentinel event” at hospital before JCAHO reports event to you; if JCAHO first notified of event
by someone else, eg, patient’s family, JCAHO gives hospital 60 to 90 days to submit comprehensive plan to fix
problem
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| Definition of sentinel event: unexpected occurrence involving death or serious physical or psychologic injury or
“risk thereof”; “sentinel” because it signals need for immediate investigation and response; implemented in 1996
to share lessons learned; every year Sentinel Event Advisory Group reviews literature and makes new goals
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| National Patient Safety Goals for 2005: verify patient identification; take “time out” to ensure accuracy of patient
identification, procedure, and medication plan before beginning procedure; improve communication among caregivers
during “sign-offs,” ie, passing patient information on to next shift; improve medication safety (standardize
drug concentrations); eliminate wrong-site surgery (involve patient); improve effectiveness of clinical alarms; reduce
infections; comply with Centers for Disease Control and Prevention (CDC) hand hygiene guidelines; reconcile
medications (compare list of medications patient taking before admission to list of drugs being given in hospital and
justify changes); reduce falls; reduce influenza and pneumococcal disease in institutionalized adults
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| National Patient Safety Goals for 2006: encourage active involvement of patients and their families in patients’
care as safety strategy; prevent pressure ulcers
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| Quality check: public disclosure of compliance with National Patient Safety Goals available in Quality Reports; results
for accredited organizations available at www.qualitycheck.org
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| Root cause analysis: JCAHO requires hospitals to find factors leading to errors
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| Institute for Healthcare Improvement (IHI) goals: improving lives of patients, health of communities, and
joy of health care workforce; connect—with your colleagues; build—your organization’s capacity to change;
apply—knowledge we have; transform—your organization at system level
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| “100K lives Campaign”: to avoid 100,000 deaths by June 2006; aims to enlist thousands of hospitals across country;
to make changes proven to prevent deaths
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| Six changes
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| Deploy rapid response team at first sign of trouble, before patient deteriorates
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| Deliver evidence-based care for acute MI
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| Prevent adverse drug events
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| Prevent central line infections
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| Prevent surgical-site infections
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| Prevent ventilator-associated pneumonia
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| National Quality Forum: endorses range of patient safety measures
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| Key health care practices
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| Create culture of safety
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| Patients considering high-risk elective procedures should be aware of outcomes at chosen hospital, compared to
other hospitals
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| Do not use abbreviations
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| Implement CPOE
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| Evaluate patient for malnutrition, DVT, pressure ulcers, and infections
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| Vaccinate health care workers
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| Agency for Healthcare Research and Quality (AHRQ): sponsors projects, eg, American College of Physicians
(ACP) training sessions on patient safety; publishes National Health Care Quality Report annually; awards grants to develop
national electronic medical record in rural areas; tracks national state of health care annually; 2004 AHRQ
findings—quality improving in many areas, but change takes time; gap between best possible care and actual care remains
large
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| Role of financial incentives: study of “pay-for-performance” in health care system published in Journal of American
Medical Association (JAMA) in 2005; found physicians offered bonus payments for implementing preventive
practices outperformed physicians not offered bonus
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| University of Miami Center for Patient Safety: received grant to research near-misses; Patient-Centered Simulation
Laboratory—allows Anesthesia and Internal Medicine residents to practice procedures; trains nurses in sterile
technique and in controlled analgesia and anesthesia for endoscopy; have mandatory 4-hr class for internal medicine interns,
including risk avoidance, medication errors, communication
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| Concluding comments: use heightened awareness to—standardize protocols; evaluate your office practice; make
changes; aim for continuous improvement
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| American College of Physicians Patient Safety Center (www.acponline.org/ptsafety)
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| Institute for Healthcare Improvement (www.ihi.org)
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| Institute for Safe Medication Practice (www.ismp.org)
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| Joint Commission on Accreditation of Healthcare Organizations (www.jointcommission.org)
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| The Leapfrog Group (www.leapfroggroup.org)
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| Agency for Healthcare Research and Quality (www.ahrq.gov)
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| The Commonwealth Fund (www.cmwf.org)
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| National Quality Forum (www.qualityforum.org)
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Educational Objectives
| The goal of this program is to educate the listener about preventing medical errors. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. Improve communication between physician and patient.
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| 2. Avoid miscommunication in ordering laboratory tests.
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| 3. Discuss potential benefits of a national electronic medical record.
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| 4. Focus on health care systems as the source and area for improvement in preventing medical errors.
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| 5. Access resources provided by major organizations dedicated to improvement of patient safety.
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Suggested Reading
Altman DE et al: Improving patient safety--five years after the IOM report. N Engl J Med 351:2041, 2004; Andrus
CH et al: "To Err Is Human": uniformly reporting medical errors and near misses, a naive, costly, and misdirected
goal. J Am Coll Surg 196:911, 2003; Berwick DM et al: The truth about doctors' handwriting: a prospective
study. BMJ 313:1657, 1996; Chaudhry B et al: Systematic review: impact of health information technology on
quality, efficiency, and costs of medical care. Ann Intern Med 144:742, 2006; Compliance data for the Joint Commission's
2004 and 2005 national patient safety goals. Jt Comm Perspect 25:7, 2005; Sentinel events statistics updated. Jt
Comm Perspect 25:4, 2005; Pelletier LR et al: New Federal Regulations for Improving Quality in Opioid Treatment
Programs. J Healthc Qual 23:29, 2001; Rosenthal MB et al: Early experience with pay-for-performance:
from concept to practice. JAMA 294:1788, 2005; Shabot MM: Automated data acquisition and scoring for JCAHO
ICU core measures. AMIA Annu Symp Proc:674, 2005; Stelfox HT et al: The "To Err is Human" report and the patient
safety literature. Qual Saf Health Care 15:174, 2006; Surbone A et al: To Err Is Human 5 years later. JAMA
294:1758, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Dr. Coronel-Couto was recorded at Internal Medicine Update 2006, sponsored by the University of Miami Miller
School of Medicine, January 22-27, 2006, in Miami, FL. The Audio-Digest Foundation thanks the speaker and the
sponsor for their cooperation in the production of this program.
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