PATIENT SAFETY AND CLINICAL COMMUNICATION

PATIENT SAFETY AND CLINICAL COMMUNICATION. PROF. LAL REHMAN FCPS, FRCS JINNAH POSTGRADUATE MEDICAL CENTRE.

In the early years of the safety field, the target was errors, and we focused on measuring and decreasing error rates. This model has given way to a new focus on measuring and attacking “harm ” or “adverse events” where harm is the “outcome” and errors are the “process.” After all, patients, quite naturally, care more about what happens to them than whether their doctor or nurse made a mistake..

We need to differentiate complications (adverse events that arise from the underlying disease) from medical harm (unintended injury caused by medical care). Not all adverse events are preventable , and those that are, usually involve errors. An error is “an act of omission (doing something wrong) or omission (failing to do the right thing) which may lead to or which causes an undesirable outcome.”.

Many errors do not result in adverse events and these are called ‘near misses’ or ‘close calls’. When the error is a result of care that falls below a professional standard of care, it’s called negligence ..

Learning from our mistakes. We need to openly acknowledge that errors are an integral part of the human experience. This will allow us to radically transform our approach to medical error. After all, one of the best ways to improve oneself is to recognize mistakes and to learn from them. The same strategy applies to providing the best patient care possible, and we need to treat medical errors as a treasure, rather than try to hide them, or shy away from discussing them..

Safety has to do with lack of harm. Safety focuses on avoiding bad events. Safety makes it less likely that mistakes happen. The ‘patient safety first’ culture needs to become part of the DNA of the healthcare system. This means committing to safety at all levels of the health facility, right from the frontline staff to doctors and nurses as well as the board of directors..

To err is human. Human error implies that if the medical team member had acted differently, the injury caused to the patient could have been prevented. We all make errors – after all, that’s what makes us human! Jens Rasmussen has suggested that errors occurred due to deficiencies in either one of the following: Skills (e.g. asking an inexperienced doctor to perform a laparotomy without supervision); Observation of rules (e.g. not washing hands before performing a procedure); or Knowledge (e.g. being unaware that gentamicin levels in the blood need to be checked)..

The truth is that medical errors can occur regardless of a doctor’s vigilance, good intentions, skill , experience or expertise. This is because medical care is a complicated system, and complex systems do fail unpredictably. What we need to do is to work on the system, so that it becomes easier for doctors and other healthcare professionals to go about discharging their duties in a more efficient, error-free manner..

Types of errors. This is the dominant model for understanding the relationship between active (“sharp end ”) errors and latent (“blunt end”) errors . Latent errors - These are the hidden root causes in the system that make active errors more likely to happen – for example, poorly designed medical records, making it easy for clinicians to misunderstand reports; or inadequate staffing, making people “rush” or routinely “multitask ”. Active errors - These occur at the level of the healthcare provider – the frontline staff that actually delivers the services, and can cause harm. These are what we think of when we think of error, due to the focus on individual acts in medicine..

Active errors can take the form of slips (doing a familiar action in the wrong way, like pouring salt instead of cream into coffee), lapses (failures of memory such that planned actions do not happen), and mistakes (errors in reasoning that lead to wrong choices). They are easier to measure because the negative outcome is much more apparent – for example , the nurse injects the wrong medication; or the doctor amputates the wrong leg..

TYPES OF MEDICAL ERRORS Errors from unintented action Attentional failures Memory failures Medical Errors Errors from intended action Violations I. Rule based Purposeful errors mistakes like 2. Knowledge sabotage (rare) based errors.

How can we make the system safer?. Here are some basic principles. Automate when appropriate Standardize – reduce reliance on memory Use checklists & standard operating procedures (SOPs) Simplify by reducing the number of steps and handoffs Add redundancy (double checks) for high-risk processes to create a safety net Stress-test the system, and try to break it, to find out the “failure points” so that these can be reduced and removed Respect the front-line staff, who are the real-life field experts, and ask them what can be done to help them do their work safely.

P atient E mpowerment - Knowledge is power!. The first conclusion most people jump to when a medical error occurs is – It was the doctor’s fault ! Patients still think of themselves as being passive recipients of medical care who are at their doctor’s mercy. However, you need to take an active role in your medical treatment, and behave as an enlightened partner - after all , your doctor is not a veterinarian ! Patients can be the first line of defense against errors, and there’s a lot you can do to protect yourself . Patient safety is not just the doctor’s responsibility – it’s the patient’s as well. Patients must play an active role in preventing medical mistakes..

An empowered patient is the CEO of her health team.

Misdiagnosis as a cause for medical errors. Doctor Most doctors know only the common diseases Different doctor skill levels Doctor bias Saving you money Lack of time Some symptoms are hard to analyze Laboratory tests and imaging studies Human errors False positives and false negatives Misinterpretation Poor quality labs Patient Self diagnosis Not reporting symptoms Failure to perform the ordered tests.

What can be done to reduce diagnostic error and harm?.

Patients are often the key to the right diagnosis.

How can doctors make medical care safer for patients?.

Never Events. A retained instrument in the abdomen after an operation A mismatched blood transfusion because of the wrong blood bag being given to a patient Surgery performed on the wrong body part Surgery performed on the wrong patient.

The new discipline of Patient Safety acknowledges that risk is inherent in medicine and error is inherent in the human condition. As Dr Lewis Thomas said eloquently, “ We are built to make mistakes, coded for error.”.

A variety of strategies have been employed to create safer systems, including: Simplification Standardization Building in redundancies Using checklists Improving teamwork Communication Learning from past mistakes.

B asic elements to improving safety:. Design the system to prevent errors occurring in the first place Design the system to make errors more visible when they do occur Design the system to limit the effects of errors so that they do not lead to harm..

Environmental factors that contribute to error include: distractions and interruptions; noise ; clutter; and poor lighting . Human factors that contribute to error include : fatigue; emotions such as boredom or frustration ; stress and distractions; and poor communication . Patient factors that contribute to error include: poor literacy; fear; and ignorance . Equipment factors that contribute to error include: confusing design; poor quality; unclear labeling ; inadequate training; and lack of availability . System factors that contribute to error include : shortage of staff; inexperienced staff; inadequate supervision; and poor workflow processes..

Technology-A boon or bane?.

Strong patient-doctor relationship. Doctors can use the 5-step SHARE Approach for shared decision making: Step 1: S eek your patient’s participation Step 2: H elp your patient explore and compare treatment options Step 3: A ssess your patient’s values and preferences Step 4: R each a decision with your patient Step 5: E valuate your patient’s decision.

What can doctors do?. Be polite, considerate, honest and patient Treat patients with dignity – not just as a medical statistic or another case Respect a patients’ right to privacy and confidentiality Support patients in caring for themselves Provide them with information and access to credible sources of medical information.

Managing mistakes.

Circumstances that increase scope for error include: Times when you are tired, lazy or overconfident When it is late at night and you are sleepy When you are angry When you are dealing with an irritating patient When the patient has a complex medical problem.

Instead of relying on memory, use preprinted forms. A good example is the use of standardized forms for post-operative orders. These simply need to be ticked and signed . They promote accurate communication; reduce variation by combining pertinent reminders , safety alerts, and evidence-based best practices; and spare doctors the clerical burden of having to repeatedly write the same orders. Flowcharts and algorithms can be helpful to prevent diagnostic errors. Personal digital assistants can serve as peripheral brains, since they can be equipped with extensive drug and clinical databases..

Factors contributing to adverse events include: Poor communication- e.g., inadequate handoffs; incomplete clinical information Failure to coordinate care- e.g., involving different specialists Excessive workload Failure to escalate care-e.g., delay or failure to involve a more senior physician or nurse Failure to recognize change in clinical status- e.g., delay in recognizing changing clinical signs and symptoms.

Dealing with mistakes. Accept responsibility for the mistake. Take ownership of the problem – the buck stops with you! Discuss it with colleagues Disclose and apologize to the patient Conduct an error analysis Make changes in your practice to reduce similar errors in the future.

Report immediately to senior. The first priority should be to attend to the patient’s medical needs. Discuss with all staff members the factual details and sequence of what occurred, and coordinate your response , to ensure that everyone is on the same page. E xpressing sincere sympathy and compassion to the patient and/or family. F actually record the incident and medical response and document plans for further follow-up. However, do not ever alter (or allow anyone else to alter) any prior documentation, or insert backdated information. Be accessible for questions from the family and the patient . Be honest with the patient and family..

Be a nice person. Be pleasant to be around. Be agreeable and friendly . Do not criticize other doctors and their care When you make a mistake, admit it-promptly . Be open and accessible . Keep up to date professionally Realize your own limitations, and ask for consultations and referrals to seniors when necessary ..

Immediately after the event: Acknowledge the event Express regret Take steps to minimize further harm Explain what happens next Commit to investigate to find out why the adverse event occurred Later follow-up Disclose the results of the internal investigation Apologize if there is an error or systems failure Make changes to prevent the failure from recurring Provide continuing emotional support to the patients and health professionals involved.