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Lessons Learned on Lessons Learned on Patient SafetyPatient Safety
Lessons Learned on Lessons Learned on Patient SafetyPatient Safety
FCC of MHRIFCC of MHRI
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The Present Culture• 12 minutes for every encounter, 18
seconds elapse before 1st interruption and 75% leave with unanswered questions.
• Medication safety: 25% of patients in a year had Adverse Drug Reaction– 11% preventable – 3% were potential to harm and 95% of these
would have been prevented
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Levels of maturity with respect to a safety culture
A. Why waste our time on safety?
B. We do something when we have an incident
C. We have systems in
place to manage all identified
risks
D. We are always on
the alert for risks that
might emerge
E. Risk management is an integral
part of everything that we do
PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE
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Safety Minefields• Transitions of Care
– 20% after discharge had a significant result: Med errors lead the pack
– Only 25% mentioned pending tests F/U
• Missed or Delayed Diagnoses• Cognitive Errors: Reliance on Memory• Test tracking, Ordering of tests and F/U• Referrals: timeliness and clarity
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Medication Pitfalls• Survey says: 200,000 Rxs written
only 72% were filled• Adherence and Medication
reconciliation– Ask-Educate-Ask
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Take home Points• Transitions of Care
– Template for first visit after discharge– Bullet points on Discharge summary of
most important topics, pending tests, labs and procedures done
– Must be available at first visit: only 12% are available
– Medication Reconcilliation at every step
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Test Tracking• No News is not good news!• How does the patient prefer to be contacted
about results: phone, e-mail, snail mail• If you do not hear from the office in X amount
of time after the study should take the initiative to contact the office.
• Order entry will help not to lose tests• Tickler systems essential for tests and
referrals• Standardize process and procedures
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Culture of Safety• Walk Rounds
– Senior level engaging and NON-punitive
• Safety Huddles: Huddles to Shape the Day and regular huddles
• Debriefings at the End of the Day and after any event.
• Event Reports: Primary Care M & M
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Culture of Safety• Need safe and supportive Accountability• Need Resources• Clinical Decision Support at P.O.C.: Algorithms • Big hitters: Cancer prevention,tests and follow
up• Communication in the office, at the hospital,
with the specialists and the administration• Consistency, Teamwork, Safe environment
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Tools• Trigger Tools• Ambulatory Safety Survey: ARQHC• MGMA: Patient Safety Score• Donabedian: Structure + Process
= Outcome• MaPSaF safety culture assessment
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Trigger Tool
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Primary Care Trigger Tool
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London Protocol
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Tool Benefits
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Individual Benefits
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Framework Document
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Next steps• Pre Huddles and post Huddles• Trigger Tool Use • Better tracking of tests, reports, reminders• Transparent Walk Rounds• Standardization for test notification, • Standardization for using EMR medication
reconcilliation• Keep up the transition of care excellence • Decision support tools in the EMR• First visit post hospitalization template• Patient surveys and practice survey tools