Safety in the Physicianís Office
Hospitals may be the focal point of most patient safety efforts, but the doctorís office needs attention too.
Of every 1,000 outpatients taking a prescription medication, 90 will seek medical attention because of a drug complication, according to Mary Pittman, Dr. P.H. (doctor of public health), president of the Health Research and Educational Trust, a Chicago-based organization affiliated with the American Hospital Association. And lost test results create a risk to patient safety and quality of care, even more so than drug interactions or office-based surgery, according to a study by the Medical Group Management Association (MGMA) and COPIC, a Colorado-based, physician-sponsored
malpractice insurer that insures about 75 percent of the eligible physicians practicing in Colorado.
"The task of improving patient safety is shared by all health care settings, but medical practices must take responsibility for learning from each other and keeping their processes current," says Terry Hammons, M.D., MGMA senior fellow. And they can start by taking a good, hard look at their own practices.
To help them do that, the Health Research and Educational Trust, MGMA and the Institute for Safe Medication Practices released in October 2006 a Web-based self-assessment tool, aptly called the Physician Practice Patient Safety Assessment (www.physiciansafetytool.org). The tool allows medical practices to evaluate daily processes that affect patient safety. Practices that complete the assessment receive a workbook designed to help them identify problem areas and pathways to improvement. For a small fee, practices can submit their data online and receive data analysis and benchmarking information.
The self-assessment tool allows practices to evaluate their effectiveness and minimize risk across multiple locations in the following areas:
- Medications (i.e., appropriate medication history, prescribing, storage, labeling, purchasing, dispensing of samples and administration of vaccines).
- Handoffs and transitions of patients between clinicians or locations (proper procedures for care coordination to track patients and their clinical information).
- Surgery and invasive procedures (patient safety issues relating to ambulatory surgery, especially sedation and anesthesia).
- Personnel qualifications and competency (appropriately assessing the qualifications of caregivers).
- Patient education and communication (actions that practices can take to help patients understand and carry out their responsibilities).
- Practice management and culture (administrative procedures to create a culture of safety).
Here are some sample assessment questions from the tool:
Is a complete medication history (including over-the-counter medications, vitamins and herbal products) obtained and documented on every patient during each office visit?
Are patients provided with an up-to-date list of all medications they are receiving upon leaving the practice or other encounter (e.g., on a wallet reference card)?
Handoffs and transitions
Are the results of laboratory, pathology and imaging tests communicated to the patient in a timely manner (24 to 48 hours), and does the practice confirm and document that the patient received the results? Are patients notified of all laboratory, pathology and imaging test results, including those that are negative, whether or not they require further clinical action?
When a patient for which the practice has responsibility is discharged from a hospital or other facility, does the practice have a system that confirms the discharge information and enter it into the patient record?
Surgery/anesthesia and sedation/invasive procedures
Has the practice identified and communicated surgical and other invasive procedures that could be performed on site to all clinicians?
Do two staff members and the patient confirm and document the site of any surgical or invasive procedure before the procedure is begun?
Does the practice maintain a system to periodically (at least annually) assess nursing and support staff competency that is appropriate for the services and procedures they perform?
Does the practice maintain a system to periodically (at least annually) assess physician competency that is appropriate for the services and procedures they perform?
Are patients assessed for their financial and physical ability to obtain prescriptions and medical supplies at the time of their office visit or when provided a prescription over the phone?
Are patients routinely asked to repeat back what they hear to help the clinician clarify any instructions?
It is likely that every practice that completes the self assessment will find some areas that need improvement, according to the authors of the tool. But that shouldnít stop them from getting a head start in improving safety and reducing the risk of harmful adverse events and future potential malpractice liability."
2007 National Patient Safety Goals
Joint Commissionís goals for 2007 focus on systemwide solutions
The Joint Commission assesses compliance with its patient safety goals through the accreditation cycle, on-site surveys and the Periodic Performance Review. Organizations failing to meet them are assigned a requirement for improvement. Failure to resolve a requirement for improvement affects the organizationís accreditation decision, which could ultimately lead to a loss of accreditation. Following are the goals and their requirements.
Goal: Improve the accuracy of patient identification.
The facility must use at least two patient identifiers when providing care, treatment or services.
Goal: Improve the effectiveness of communication among caregivers.
For verbal or telephone orders or for telephonic reporting of critical test results, caregivers must verify the complete order or test result by having the person receiving the information record and "read-back" the complete order or test result.
The facility must standardize a list of abbreviations, acronyms, symbols and dose designations that are not to be used throughout the organization.
The facility should implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions.
Goal: Improve the safety of using medications.
The facility should standardize and limit the number of drug concentrations it uses.
The facility should identify and, at a minimum, annually review a list of look-alike/sound-alike drugs, and take action to prevent errors involving the interchange of these drugs.
The facility should label all medications, medication containers (for example, syringes, medicine cups, basins) or other solutions on and off the sterile field.
Goal: Reduce the risk of healthcare-associated infections.
The facility should comply with current Centers for Disease Control and Prevention hand hygiene guidelines.
The facility should manage as sentinel events
all identified cases of unanticipated death or major permanent loss of function associated with a healthcare-associated infection.
Goal: Accurately and completely reconcile medications across the continuum of care.
The facility should ensure that there is a process for comparing the patientís current medications with those ordered for the patient while under its care.
A complete list of the patientís medications should be communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications should also be provided to the patient on discharge from the organization.
Goal: Reduce the risk of patient harm resulting from falls.
The facility should implement a fall-reduction program including an evaluation of its effectiveness.
Goal: Encourage patientsí active involvement in their own care as a patient safety strategy.
Define and communicate the means for patients and their families to report concerns about safety, and encourage them to do so.
Goal: The organization identifies safety risks inherent in its patient population.
The facility should identify patients at risk for suicide (for patients in psychiatric hospitals or for patients being treated for emotional or behavior disorders in general hospitals).
In its 2007 goals, the Joint Commission takes special
care to identify ways in which healthcare providers can prevent wrong-site, wrong-procedure and wrong-person surgery. The so-called "Universal Protocol" is based on
the consensus of a number of clinical specialties and professional disciplines, and is endorsed by more than
40 professional medical associations and organizations, according to the Joint Commission. The following steps, taken together, comprise the Universal Protocol:
Pre-operative verification process
Purpose: To ensure that all of the relevant documents
and studies are available prior to the start of the procedure and that they have been reviewed and are consistent with each other and with the patientís expectations and with
the teamís understanding of the intended patient, procedure, site and, as applicable, any implants. Missing information or discrepancies must be addressed before starting the procedure.
Process: An ongoing process of information gathering and verification, beginning with the determination to do the procedure, continuing through all settings and interventions involved in the preoperative preparation of the patient,
up to and including the "time out" just before the start of the procedure.
Marking the operative site.
Purpose: To identify unambiguously the intended site of incision or insertion.
Process: For procedures involving right/left distinction, multiple structures (such as fingers and toes), or multiple levels (as in spinal procedures), the intended site must be marked such that the mark will be visible after the patient has been prepped and draped.
"Time out" immediately before starting the procedure.
Purpose: To conduct a final verification of the correct patient, procedure, site and, as applicable, implants.
Process: Active communication among all members of the surgical/procedure team, consistently initiated by a designated member of the team, conducted in a "fail-safe" mode, i.e., the procedure is not started until any questions or concerns are resolved.
For a full description of all the goals, their requirements, rationale for requirement and implementation expectations, visit the Joint Commission website at www.jointcommission.org.
A culture of safety demands action
A true culture of safety in hospitals moves beyond merely encouraging healthcare workers and clinicians to work toward change, according to the Institute for Healthcare Improvement (Cambridge, Mass.). In a culture of safety, people take action when necessary. Safety becomes everyoneís responsibility, and no one points a finger at others for reporting unsafe conditions.
The Institute of Healthcare Improvement recommends the following steps to facilitate safety within an organization:
- Relay safety reports at shift changes. Identifying higher-risk situations and bringing them to the attention of staff at the start of each shift decreases the likelihood of adverse events and errors. For example, healthcare workers and clinicians should be informed of patients with the same last name, trials of new equipment and research protocols. One person should be responsible for collecting and relaying information for each shift. Safety information should also be shared with staff in other departments who work with patients on the units.
- Create an adverse event response team. Following an adverse event, members of the response team should take immediate action, keeping the atmosphere calm and curtailing any undue punitive action. They should review what happened and support family, staff, and employed and non-employed physicians. Enough staff members should be trained to be part of the response team, ensuring the team is in place 24 hours a day, seven days a week. A backup group of responders is needed in case members of the response team are involved in the adverse event.
- Reenact real adverse events from the hospital. Videotaping staff members and physicians reenacting adverse events can teach others how to avoid similar mistakes in the future.
- Appoint a safety champion for every unit. Communicating information about patient safety should not always be the responsibility of hospital management. Having a staff member in this role demonstrates the organizationís commitment to safety and may make other staff members feel more comfortable about sharing information. Champions must have proper training, resources and authority.
- Simulate possible adverse events. Simulations provide debriefing opportunities for people involved in adverse events or near misses. Use an empty patient room for simulations. It costs little and often already has the necessary equipment.
- Involve patients in safety initiatives. Involving patients can make them feel valued, and their questions and comments often indicate possible errors. Invite patients and families to take part in multidisciplinary rounds and ask for their comments. Patients and family members can monitor compliance with safe practices (e.g. they can make sure no one administers medication without verifying the patient identification). They also can serve on patient safety committees.
- Create a reporting system. Adopt a non-punitive reporting policy where management shows its support. Let reporters know that something will be done about their report. Show them the system works.
- Designate a patient safety officer. A patient safety officer promotes action through training of staff and implementation of proven methods. The patient safety officer should be educated to continually seek best practices. He or she should have the authority to act and remove barriers to change. In addition, the patient safety officer should meet regularly with the CEO and make regular presentations to the organizationís board.
- Conduct safety briefings. Safety briefings are tools to increase safety awareness among front-line staff and foster a culture of safety. Management should reinforce the non-punitive aspect of the discussion repeatedly, especially during the first few briefings. Briefings should be short and include detailed information about issues raised by staff.
- Provide feedback to frontline staff. Maintaining a consistent flow of information from senior leadership to the staff affirms that every safety initiative is important. The feedback system must reach all staff members, including those who work on alternate shifts, weekends or intermittently. Feedback should be timely.
- Conduct patient safety leadership WalkRounds. WalkRounds are regular rounds for the sole purpose of discussing safety with the staff. During the WalkRounds, communication should go two ways, with both executives and staff interacting and listening to one another. WalkRounds should be scheduled for one hour every week, and discussions should stay focused on safety. Executives should follow up with feedback