A modest proposal: Teaching A modest proposal: Teaching Patient Safety in the Medical Patient Safety in the Medical

School CurriculumSchool CurriculumRobert Boorstein, MD, PhDRobert Boorstein, MD, PhD

Bellevue Hospital Center, NYU School Bellevue Hospital Center, NYU School of Medicineof Medicine

Case 1: A 50 y.o. man Case 1: A 50 y.o. man with CMLwith CML A bone marrow specimen is sent for A bone marrow specimen is sent for

cytogenetic analysis. The cytogeneticist cytogenetic analysis. The cytogeneticist reports a pattern consistent with advanced reports a pattern consistent with advanced AML and 2 X chromosomes, and no Y AML and 2 X chromosomes, and no Y chromosome. Why was the test performed, chromosome. Why was the test performed, and what is the likely cause of this result?and what is the likely cause of this result?

– From 4From 4thth year “selective”, “Rational Utilization of year “selective”, “Rational Utilization of the Clinical Laboratory”, NYU School of Medicine.the Clinical Laboratory”, NYU School of Medicine.

Revolutions in Medical EducationRevolutions in Medical Education

• Scientific Basis of Medical Practice

• Analytical Reasoning• Clinical Investigation• Underlying Moral

Basis

Revolutions in Medical Education IIRevolutions in Medical Education II

• Primacy of Doctor Patient interaction

• Patient centric, not disease centric

• Social context of disease

• Access to care

• Patient diversity

• Compassion, empathy

• Limits to physicians abilities

Physicians must be altruistic!Physicians must be altruistic!

For its part the medical school must ensure that before graduation a student will have demonstrated, to the satisfaction of the faculty, the following:

• Knowledge of the theories and principles that govern ethical decision making, and of the major ethical dilemmas in medicine, particularly those that arise at the beginning and end of life and those that arise from the rapid expansion of knowledge of genetics

• Compassionate treatment of patients, and respect for their privacy and dignity

• Honesty and integrity in all interactions with patients’ families, colleagues, and others with whom physicians must interact in their professional lives

• An understanding of, and respect for, the roles of other health care professionals and of the need to collaborate with others in caring for individual patients and in promoting the health of defined populations

• A commitment to advocate at all times the interests of one’s patients over one’s own interests

• An understanding of the threats to medical professionalism posed by the conflicts of interest inherent in various financial and organizational arrangements for the practice of medicine.

• The capacity to recognize and accept limitations in one’s knowledge and clinical skills, and a commitment to continuously improve one’s knowledge and ability

• msop1.pdf

Topics missing from MSOPTopics missing from MSOP

• Patient Safety

• Practice Guidelines

• Clinical Protocols

• Medical Errors

• Risk Reduction

• Engineering

• Training

LCME: Educational ObjectivesLCME: Educational Objectives

• Content. The curriculum must include behavioral and socioeconomic subjects, in addition to basic science and clinical disciplines. It must include the contemporary content of those disciplines that have been traditionally titled anatomy, biochemistry, genetics, physiology, microbiology and immunology, pathology, pharmacology and therapeutics, and preventive medicine. Instruction within the basic sciences should include laboratory or other practical opportunities for the direct application of the scientific method, accurate observation of biomedical phenomena, and critical analysis of data. [Technical revision approved June 2006, effective immediately.]

• Liaison Committee on Medical Education Home Page• LCME F&S Text.htm

• ToErr-8pager.pdf

100,000 lives campaign100,000 lives campaign

• Institute for Health Initiatives

100,000 Lives Campaign Objectives (December 2004 – June 2006)

• Save 100,000 lives

• Enroll more than 2,000 hospitals in the initiative

• Build a reusable national infrastructure for change

• Raise the profile of the problem (variability in the quality of American health care) - and our proactive response

The 100,000 Lives Campaign Scorecard

• An estimated 122,300 lives saved by participating hospitals

• Over 3,100 hospitals enrolled– Over 78% of all discharges– Over 78% of all acute-care beds– Over 85% of participating hospitals sending IHI mortality data

• Participation in Campaign interventions:Rapid Response Teams: 60%AMI Care Reliability: 77%Medication Reconciliation: 73%Surgical Site Infection Bundles: 72%Ventilator Bundles: 67%Central Venous Line Bundles: 65%All six: 42%

An Introduction to the 5 Million Lives Campaign

December 12, 2006

The PlatformThe six interventions from the 100,000 Lives Campaign:

• Deploy Rapid Response Teams…at the first sign of patient decline

• Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction…to prevent deaths from heart attack

• Prevent Adverse Drug Events (ADEs)…by implementing medication reconciliation

• Prevent Central Line Infections…by implementing a series of interdependent, scientifically grounded steps

• Prevent Surgical Site Infections…by reliably delivering the correct perioperative antibiotics at the proper time

• Prevent Ventilator-Associated Pneumonia…by implementing a series of interdependent, scientifically grounded steps

The PlatformNew interventions targeted at harm:

• Prevent Pressure Ulcers... by reliably using science-based guidelines for their prevention

• Reduce Methicillin-Resistant Staphylococcus aureus (MRSA) Infection…by reliably implementing scientifically proven infection control practices

• Prevent Harm from High-Alert Medications... starting with a focus on anticoagulants, sedatives, narcotics, and insulin

• Reduce Surgical Complications... by reliably implementing all of the changes in care recommended by the Surgical Care Improvement Project (SCIP)

• Deliver Reliable, Evidence-Based Care for Congestive Heart Failure…to reduce readmissions

• Get Boards on Board….Defining and spreading the best-known leveraged processes for hospital Boards of Directors, so that they can become far more effective in accelerating organizational progress toward safe care

The Platform

…plus numerous other interventions that hospitals must introduce in order to contribute to meeting our aim.

Joint Commission: National Patient Joint Commission: National Patient Safety GoalsSafety Goals

• http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/

2007 Critical Access Hospital and 2007 Critical Access Hospital and Hospital National Patient Safety Hospital National Patient Safety

GoalsGoalsGoal 1. Improve the accuracy of patient identification.

Goal 2. Improve the effectiveness of communication among caregivers.

Goal 3. Improve the safety of using medications.

Goal 7. Reduce the risk of health care-associated infections.

Goal 8. Accurately and completely reconcile medications across the continuum of care.

Key Concept: Patient Safety, Key Concept: Patient Safety, and the clinicians role in and the clinicians role in improving patient safetyimproving patient safety

Medical School Objectives ProjectMedical School Objectives Project• For its part the medical school must ensure that before graduation a student will have

demonstrated, to the satisfaction of the faculty, the following:

• The ability to understand the physician’s role as a member of a team delivering care within a local clinical care environment (micro-system)

• The ability to integrate information technology into the improvement of patient care

• The ability to describe the principles of a quality improvement initiative that maximizes patient safety, despite barriers and variability in the practice environment

• The understanding of, by way of direct participation in the design, implementation and testing of change for the improvement of patient care

• The ability to learn from one’s own practices and corresponding efforts to improve them

• AAMC/2001 Report V - Contemporary Issues in Medicine: Quality of Care 7

A paradoxA paradox

• Despite ongoing changes in curriculum, and intensive introspection and self study, medical education is lagging behind medical practice

• Medical Schools need to produce physicians at the forefront (or at least not the rearguard) in the change in medical practice.

• Changes that are needed do not fit neatly into the “attitudes, knowledge, skills, behaviors” framework

Values for Medical Practice in the 21Values for Medical Practice in the 21stst centurycentury

• Results oriented (not process)• Measurable• Accountable (to society, not just to the profession or to patients)• Redundancy• Transparency• Embracing of training• Information dependent• Risk reduction• Error prevention• Primacy of systems, not individual judgment

Words convey valuesWords convey values

• Good– Problem Solving– Reasoning– Evidence based medicine

• (interpretation of literature)

– Thinking like a physician– Physician autonomy– Reading the literature

• Bad– Cook-book medicine– Rote Learning– Training– Repetition– Non-physician oversight– Choreographed– Stereotyped– Protocol– Standardization– Following the literature– Documentation

What is now being taughtWhat is now being taught

• National Patient Safety Goals

• 100,000 Lives Campaign

• Medical School Objective Project

• Very little systematic coverage of medical errors, patient safety, and principles of medical systems, in the medical curriculum

Where to teachWhere to teach

• Ideally, day one.

• Ideally, everywhere

• Second year curriculum

• 4th year curriculum

• Case based approaches are ideal for these issues.

Second year “pathology”Second year “pathology”

• Rationale and use of clinical algorithms

• Importance of precise communication

• Introduction to National Patient Safety goals

44thth year “selective” in “Utilization of the year “selective” in “Utilization of the Clinical Laboratory”Clinical Laboratory”

• 2 weeks

• 2 hours /day

• 3 cases/day

• 12 students per section

• All teaching case based, student led.

• Initial and final evaluation using audience response monitors

Case 3: A 42 year old man Case 3: A 42 year old man with adenocarcinoma of the with adenocarcinoma of the GE junctionGE junction A patient complains of upper A patient complains of upper

GI discomfort. The patient is endoscoped, GI discomfort. The patient is endoscoped, and a small biopsy obtained from the GE and a small biopsy obtained from the GE junction. After much debate, the sample junction. After much debate, the sample is diagnosed as adenocarcinoma. The is diagnosed as adenocarcinoma. The patient undergoes definitive surgery. patient undergoes definitive surgery. Upon analysis, no tumor is found in the Upon analysis, no tumor is found in the resected stomach.resected stomach.– How do you explain this. What do you tell the How do you explain this. What do you tell the

patient.patient.

Case 4: A 65 year old man Case 4: A 65 year old man being treated with coumadinbeing treated with coumadin

A patient comes to clinic, and you A patient comes to clinic, and you suspect the coumadin dose is much too suspect the coumadin dose is much too high. You draw a PT/PTT and sent it to high. You draw a PT/PTT and sent it to the lab STAT. Two hours later, you call the lab STAT. Two hours later, you call the lab, and they tell you that the the lab, and they tell you that the specimen is being processed. You call specimen is being processed. You call back two hours later and they tell you back two hours later and they tell you the same thing.the same thing.– What do you do?What do you do?

44thth year “selective” in “Utilization of the year “selective” in “Utilization of the Clinical Laboratory”Clinical Laboratory”

• Integration of issues related to patient safety, utilization, reliability, algorithm development, communication, reporting and cost into discussions of clinical utility and underlying biomedical principles

• Begin to cover the MSOP: Quality of Care goals

Future DirectionsFuture Directions

• A patient safety curriculum, from medical school through residency

• Assessment of curriculum efficacy