copyright 2005 partners radiology patient safety training “error free patient & site...

Copyright 2005 Partners Radiology

Patient Safety Training Patient Safety Training

““Error Free Patient & Site Identification”Error Free Patient & Site Identification”

Partners Radiology Patient Safety TeamPartners Radiology Patient Safety Team


GoalGoal

““Improve patient safety by providing Improve patient safety by providing tools to assess staff competency in error tools to assess staff competency in error

free patient and site identification”free patient and site identification”


ObjectivesObjectives

At the end of the training the participant will be able At the end of the training the participant will be able to:to:

– Identify how errors occur (causes)Identify how errors occur (causes)– Identify effects of errors on patient, department Identify effects of errors on patient, department

and hospitaland hospital– Discuss countermeasuresDiscuss countermeasures– Define & deploy the hospital specific patient Define & deploy the hospital specific patient

identification processidentification process– Understand how to employ various methods for Understand how to employ various methods for

competency assessmentcompetency assessment


MethodologyMethodology

Blame-free Approach – Blame-free Approach – Share incidents, policies, Share incidents, policies, procedures and risk reduction strategies employed procedures and risk reduction strategies employed

Failure Modes & Effects Analysis Approach Failure Modes & Effects Analysis Approach (FMEA) -(FMEA) - Identify true cause and effects of sentinel Identify true cause and effects of sentinel and adverse events and proactively prevent such and adverse events and proactively prevent such high-risk events from occurring by implementing high-risk events from occurring by implementing selective countermeasures.selective countermeasures.

Root Cause Analysis – Root Cause Analysis – Analyze adverse and Analyze adverse and sentinel events retrospectively to identify failures in sentinel events retrospectively to identify failures in systems and processessystems and processes


Target AudienceTarget Audience All clinical and non-clinical personnel All clinical and non-clinical personnel involved in the patient & site involved in the patient & site identification identification process - Technologists, process - Technologists, MDs, RNs and Support StaffMDs, RNs and Support Staff


Case Study 1Case Study 1

Correct patient/Incorrect chartCorrect patient/Incorrect chartNon-compliance with patient Non-compliance with patient

identification procedureidentification procedure



Mr. ChenMr. Chen in room 426A has been ordered in room 426A has been ordered for a biliary drainage tube. for a biliary drainage tube.

Transport is called to bring down Transport is called to bring down Mr. ChanMr. Chan in 428A for an abdominal CT scan. in 428A for an abdominal CT scan.

15 minutes later, transport is called to bring 15 minutes later, transport is called to bring patient in 426A.patient in 426A.


The patient is brought to interventional The patient is brought to interventional radiology.radiology.

The nurse and tech review the chart for The nurse and tech review the chart for Mr. Mr. ChanChan and confirm the written MD order for and confirm the written MD order for the biliary procedure. the biliary procedure.

During the consent process the patient During the consent process the patient appears to understand, nods his head in appears to understand, nods his head in agreement and signs the consent. agreement and signs the consent.



The procedure progresses with no The procedure progresses with no complications up until the guide wire is complications up until the guide wire is removed. As the guide wire is removed, it is removed. As the guide wire is removed, it is followed by a large gush of arterial blood. followed by a large gush of arterial blood.

Surgical consult is immediately called and Surgical consult is immediately called and patient is rushed to the OR for emergency patient is rushed to the OR for emergency surgery of his hepatic artery.surgery of his hepatic artery.



Meanwhile in CT, Meanwhile in CT, Mr. ChenMr. Chen is asking when is asking when his biliary tube placement is scheduled for? his biliary tube placement is scheduled for? The CT tech calls interventional radiology The CT tech calls interventional radiology and asks when and asks when Mr. ChenMr. Chen is scheduled for is scheduled for his biliary drainage tube. his biliary drainage tube. The interventional tech replies, “We just The interventional tech replies, “We just finished the biliary drainage tube finished the biliary drainage tube placement. I better call you back”.placement. I better call you back”.



What happened?What happened?



What happened?What happened? Two patients with similar names on same Two patients with similar names on same

floorfloorTransport called for patient by room Transport called for patient by room

number onlynumber onlySecretary/Unit coordinator gave transport Secretary/Unit coordinator gave transport

incorrect information due to similarity of incorrect information due to similarity of namesnames

Patient was addressed by procedure namePatient was addressed by procedure name



Language barrier not recognized during Language barrier not recognized during rush to consent patientrush to consent patient

Disregard for policy – no one verified name Disregard for policy – no one verified name and date of birth with patient chartand date of birth with patient chart

Disregard for policy – no one verified Disregard for policy – no one verified written order and patient’s armbandwritten order and patient’s armband




EffectsEffects

Patient exposed to unnecessary invasive radiology Patient exposed to unnecessary invasive radiology procedure, which resulted in complications procedure, which resulted in complications (PE)(PE)

Patient almost died Patient almost died (PE, RE, HE)(PE, RE, HE) Increased length of stay/ICU stay Increased length of stay/ICU stay (HE)(HE) Malpractice liability Malpractice liability (HE, RE)(HE, RE) Patient inconvenience & decrease in patient Patient inconvenience & decrease in patient

confidence confidence (PE)(PE)


PE – Patient effects; HE – Hospital effects; PE – Patient effects; HE – Hospital effects; RE – Radiology effectsRE – Radiology effects


EffectsEffectsCase Study 1Case Study 1


Delay in treatment of Mr. Chen Delay in treatment of Mr. Chen (PE)(PE) Patient care issue Patient care issue (RE, HE)(RE, HE) DPH review of case DPH review of case (HE)(HE) Delay in treatment of Mr. Chan Delay in treatment of Mr. Chan (PE)(PE) Increased length of stay Increased length of stay (HE, PE)(HE, PE)


CountermeasuresCountermeasures


Correct patient ID procedure – use of 2 Correct patient ID procedure – use of 2 valid patient identifiers – Active valid patient identifiers – Active verification verification

(Ask patient to state name (Ask patient to state name and DOB)and DOB)

Compliance with patient identification Compliance with patient identification policypolicy


QuestionsQuestions


Which of the following should be employed for Which of the following should be employed for correct patient ID using patients specific name?correct patient ID using patients specific name?

1. Call for the patient using patient’s last name only 1. Call for the patient using patient’s last name only (compliance with confidentiality)(compliance with confidentiality)

2. Ask the patient to state their first and last name2. Ask the patient to state their first and last name

3. State to the patient “ Your name is….”3. State to the patient “ Your name is….”

4. 4. Provide hospital interpreter service and/or Provide hospital interpreter service and/or arrange for legal guardianarrange for legal guardian


QuestionsQuestions


Which of the following could be employed for a Which of the following could be employed for a second patient identifier?second patient identifier?

1. Patient’s DOB1. Patient’s DOB

2. MRN2. MRN

3. Referring physician's name3. Referring physician's name

4. Date of last exam4. Date of last exam

5. Patient location or room number5. Patient location or room number


Wrong patient scheduled by Wrong patient scheduled by physician’s officephysician’s office



Melanie Murphy, 45 year old female, arrives Melanie Murphy, 45 year old female, arrives at Dr. Feel Good’s office. Dr. Feel Good at Dr. Feel Good’s office. Dr. Feel Good instructs the secretary to order a CT study for instructs the secretary to order a CT study for Ms. Murphy. The harried secretary quickly Ms. Murphy. The harried secretary quickly schedules the exam and sends the patient to schedules the exam and sends the patient to Radiology. Radiology.



Upon Ms. Murphy’s arrival in Radiology, the Upon Ms. Murphy’s arrival in Radiology, the receptionist confirms the patient name, receptionist confirms the patient name, checks her in and enters the requisition for checks her in and enters the requisition for Melanie Murphy. Melanie Murphy.

On receiving the requisition, the technologist On receiving the requisition, the technologist goes to the waiting room and calls for goes to the waiting room and calls for Melanie Murphy.Melanie Murphy.



Ms. Murphy stands up and follows the Ms. Murphy stands up and follows the technologist to the exam room. The technologist to the exam room. The technologist confirms the patient name and technologist confirms the patient name and referring physician’s name and completes referring physician’s name and completes exam.exam.

Subsequently, Melanie Murphy goes for a Subsequently, Melanie Murphy goes for a follow-up visit to Dr. Feel Good’s office and follow-up visit to Dr. Feel Good’s office and the doctor discovers that he has not received the doctor discovers that he has not received any report for the exam in the system.any report for the exam in the system.



Referring MD’s secretary entered the wrong exam Referring MD’s secretary entered the wrong exam information – incorrect DOB and/or MRNinformation – incorrect DOB and/or MRN

Radiology receptionist confirmed patient ID with Radiology receptionist confirmed patient ID with one identifier – “patient name”one identifier – “patient name”

RT used one valid form of ID (patient name) and RT used one valid form of ID (patient name) and one invalid form of ID (referring MD’s name)one invalid form of ID (referring MD’s name)

Referring MD did not use an ID specific only to Referring MD did not use an ID specific only to that patientthat patient – made an order based on patients – made an order based on patients name onlyname only




Patient inconvenience Patient inconvenience (PE)(PE) Decrease in patient satisfaction/confidence Decrease in patient satisfaction/confidence (PE)(PE) Correct patient did not get results Correct patient did not get results (PE & RE)(PE & RE) Delay in diagnosis Delay in diagnosis (PE & RE)(PE & RE) Wrong patient billed – Medicare fraud Wrong patient billed – Medicare fraud (PE, RE & (PE, RE &

HE)HE) Revenue loss Revenue loss (RE & HE)(RE & HE)

Case Study 2Case Study 2EffectsEffects



Exam results sent to wrong patient chart – HIPAA Exam results sent to wrong patient chart – HIPAA violation violation (PE, HE & RE)(PE, HE & RE)

Decrease in MD satisfaction Decrease in MD satisfaction (RE & HE)(RE & HE) Litigation issue Litigation issue (RE & HE)(RE & HE) Patient care issue Patient care issue (RE & HE)(RE & HE) Compliance issue – Medicare Fraud/HIPAA Compliance issue – Medicare Fraud/HIPAA

violation violation (RE & HE)(RE & HE)

Case Study 2Case Study 2EffectsEffects



CountermeasuresCountermeasures Ordering physician should confirm ordersOrdering physician should confirm orders Secretary in office should verify two forms of Secretary in office should verify two forms of

patient ID (Patient name & DOB)patient ID (Patient name & DOB) Radiology receptionist should verify two forms of Radiology receptionist should verify two forms of

patient specific identification (JCAHO specific)patient specific identification (JCAHO specific) RT should verify two forms of patient specific RT should verify two forms of patient specific

identification (JCAHO specific)identification (JCAHO specific)




QuestionsQuestionsTrue/FalseTrue/False Physicians are not responsible for correctly Physicians are not responsible for correctly identifying patients.identifying patients. Technologist does not need to identify patient as Technologist does not need to identify patient as

long as the radiology receptionist has done so.long as the radiology receptionist has done so. The radiology receptionist does not need to verify The radiology receptionist does not need to verify

the patient’s DOB as long as their name is on the the patient’s DOB as long as their name is on the schedule.schedule.


Results sent with Results sent with wrong patient namewrong patient name



It is a hectic day in ultrasound. There are It is a hectic day in ultrasound. There are multiple ultrasound guided biopsies multiple ultrasound guided biopsies scheduled.scheduled.

The unit coordinator has prepared the The unit coordinator has prepared the needed paperwork for the procedures. She needed paperwork for the procedures. She affixes patient labels to unused specimen affixes patient labels to unused specimen containers.containers.



Mr. Robinson with metastatic colon cancer Mr. Robinson with metastatic colon cancer arrives in ultrasound and is brought into arrives in ultrasound and is brought into room 1. room 1. Mr. Smith also arrives for his core liver Mr. Smith also arrives for his core liver biopsy and is brought into room 2. biopsy and is brought into room 2. Both patients’ core liver biopsies are Both patients’ core liver biopsies are performed after correct patient performed after correct patient identification and time out.identification and time out.



The nurse in room 2 realizes that there is no The nurse in room 2 realizes that there is no specimen container in the room. The MD specimen container in the room. The MD has the specimen ready, so the nurse rushes has the specimen ready, so the nurse rushes from the room. from the room. She sees one container labeled on the She sees one container labeled on the counter and retrieves it. The MD then counter and retrieves it. The MD then deposits the specimen into the container. deposits the specimen into the container. The specimens for Mr. Smith and Mr. The specimens for Mr. Smith and Mr. Robinson are then sent to the lab.Robinson are then sent to the lab.



The pathology report for Mr. Robinson The pathology report for Mr. Robinson returns as benign fatty liver. The report for returns as benign fatty liver. The report for Mr. Smith unfortunately shows malignant Mr. Smith unfortunately shows malignant metastatic disease. metastatic disease. Mr. Robinson is discharged and is Mr. Robinson is discharged and is scheduled for a 6-month follow-up liver scheduled for a 6-month follow-up liver scan. scan.



While in the hospital, a course of treatment While in the hospital, a course of treatment is planned for Mr. Smith and treatment is planned for Mr. Smith and treatment includes a combination of chemotherapy includes a combination of chemotherapy and radiation therapy.and radiation therapy.During the course of his treatment, he During the course of his treatment, he becomes immunosuppressed and develops becomes immunosuppressed and develops serious MRSA pneumonia, from which he serious MRSA pneumonia, from which he succumbs. succumbs.



On autopsy it is noted that Mr. Smith had a On autopsy it is noted that Mr. Smith had a fatty liver but no evidence of ever having liver fatty liver but no evidence of ever having liver metastasis. metastasis. Mr. Robinson returns prior to his 6-month Mr. Robinson returns prior to his 6-month follow-up with severe abdominal pain, jaundice, follow-up with severe abdominal pain, jaundice, increased bilirubin count and fever. CT and increased bilirubin count and fever. CT and Ultrasound exams confirm multiple large liver Ultrasound exams confirm multiple large liver lesions, lymphadenopathy and ascites. Palliative lesions, lymphadenopathy and ascites. Palliative treatment and hospice care are initiated.treatment and hospice care are initiated.



Neither the MD nor the RN verified patient Neither the MD nor the RN verified patient identification on label of container versus identification on label of container versus patient identification on band and patient identification on band and requisition.requisition.

Lab failed to verify patient identification on Lab failed to verify patient identification on requisition with label on container.requisition with label on container.




Patient inconvenience Patient inconvenience (PE)(PE) Decrease in family confidence Decrease in family confidence (PE)(PE) Delay in treatment leading to death Delay in treatment leading to death (PE, HE)(PE, HE) Correct patient did not get results Correct patient did not get results (PE, RE)(PE, RE) Non-traceable specimen Non-traceable specimen (PE, RE)(PE, RE) Decrease in MD satisfaction Decrease in MD satisfaction (HE)(HE)

EffectsEffectsPE – Patient effects; HE – Hospital effects; PE – Patient effects; HE – Hospital effects;

RE – Radiology effectsRE – Radiology effects



Litigation issue Litigation issue (HE)(HE) Patient care issue Patient care issue (PE, HE)(PE, HE) Compliance issue Compliance issue (HE, RE)(HE, RE) Wrong patient billed Wrong patient billed (HE, RE, PE)(HE, RE, PE) DPH review of case and bad publicity DPH review of case and bad publicity (HE)(HE) Pain and suffering for both patient and their Pain and suffering for both patient and their

families families (PE)(PE)


RE – Radiology effectsRE – Radiology effects




CountermeasuresCountermeasures Technologist needs to verify all items related to Technologist needs to verify all items related to care of patient – care of patient – label of container, requisition label of container, requisition and and arm bandarm band Lab needs to follow correct patient identification Lab needs to follow correct patient identification

processprocess Nurse or Technologist should assure all proper Nurse or Technologist should assure all proper equipment is in the room before procedure startsequipment is in the room before procedure starts



QuestionsQuestions Who was responsible for verifying that the Who was responsible for verifying that the

label ID was correct?label ID was correct?

1.1.Unit coordinatorUnit coordinator

2.2.RNRN

3.3.RTRT

4.4.RadiologistRadiologist

5.5.Receiving personnel in labReceiving personnel in lab


Case Study 4Case Study 4 Wrong side entered in requisitionWrong side entered in requisition

Original images misread/mislabeled Original images misread/mislabeled /incorrect report/incorrect report

Failure to follow site verification processFailure to follow site verification process



Mr. Peter Van Don, a 60 year old male Mr. Peter Van Don, a 60 year old male patient with peripheral vascular disease patient with peripheral vascular disease and bilateral renal artery stenosis was and bilateral renal artery stenosis was referred by his nephrologist to a referred by his nephrologist to a radiologist for angiography and possible radiologist for angiography and possible stenting of the left renal artery.stenting of the left renal artery.



The patient was scheduled for his The patient was scheduled for his procedure in the usual fashion, which was procedure in the usual fashion, which was later cancelled by the patient himself. In later cancelled by the patient himself. In the process of rescheduling the patient, the the process of rescheduling the patient, the radiologist rescheduled the patient but not radiologist rescheduled the patient but not in the radiology scheduling system. in the radiology scheduling system.



When the patient arrived for his When the patient arrived for his appointment, he did not appear on the appointment, he did not appear on the radiology schedule and the procedure team radiology schedule and the procedure team was not expecting him. The only was not expecting him. The only information about the patient was on a information about the patient was on a procedure planning board. This information procedure planning board. This information included “Renal arteriogram/Stenting”. included “Renal arteriogram/Stenting”.

He was treated as an add-on.He was treated as an add-on.



The radiologist who rescheduled the The radiologist who rescheduled the procedure was not present on this morning procedure was not present on this morning to present the patient’s history at the to present the patient’s history at the morning rounds but was expected to morning rounds but was expected to perform the procedure later in the day.perform the procedure later in the day.



One of the fellows was dispatched to the One of the fellows was dispatched to the floor to obtain consent. He obtained a floor to obtain consent. He obtained a history from the patient and wrote a pre-history from the patient and wrote a pre-procedure note indicating that the patient procedure note indicating that the patient has left renal artery stenosis: plan has left renal artery stenosis: plan procedure angiogram/stenting. procedure angiogram/stenting.

The consent form was signed by the The consent form was signed by the patient but did not indicate which renal patient but did not indicate which renal artery would be involved. artery would be involved.



The original radiologist who planned to do The original radiologist who planned to do the procedure needed to leave at 4pm and the procedure needed to leave at 4pm and signed out the procedure to the on call signed out the procedure to the on call radiologist. radiologist.

He provided a verbal report that the patient He provided a verbal report that the patient had a stenotic renal artery and needed an had a stenotic renal artery and needed an angiogram and possible stenting; angiogram and possible stenting; he did he did not specify a side.not specify a side.



By the time the patient was called to the By the time the patient was called to the procedure room the fellow who had procedure room the fellow who had obtained consent was scrubbed in another obtained consent was scrubbed in another procedure. procedure.

The pre-procedure note, consent form and The pre-procedure note, consent form and nursing assessment were in the patient’s nursing assessment were in the patient’s medical record and brought into the medical record and brought into the procedure room along with the patient.procedure room along with the patient.



The nurse’s assessment and the The nurse’s assessment and the nephrologist’s progress note stated that the nephrologist’s progress note stated that the patient was here for left artery arteriogram patient was here for left artery arteriogram and stent and the right kidney was not and stent and the right kidney was not salvageable. salvageable.



The on call radiologist and the new fellow The on call radiologist and the new fellow assigned to this procedure did not review assigned to this procedure did not review the documents in the chart prior to the the documents in the chart prior to the procedure and did not review MRA as the procedure and did not review MRA as the computer had crashed and they did not computer had crashed and they did not want to reboot it.want to reboot it.



Under direct visualization in the Under direct visualization in the arteriogram, the left renal artery could not arteriogram, the left renal artery could not be visualized but stenosis was noted in the be visualized but stenosis was noted in the right renal artery. right renal artery.

The radiologist believed that the right The radiologist believed that the right renal artery was the one requiring renal artery was the one requiring treatment and proceeded with stenting and treatment and proceeded with stenting and opened blood flow to the unsalvageable opened blood flow to the unsalvageable kidney.kidney.



After completing the procedure, the tech After completing the procedure, the tech asked the radiologist “Are we going to go asked the radiologist “Are we going to go on and treat the left renal artery”. on and treat the left renal artery”.

The patient overheard this and commented The patient overheard this and commented “You mean you placed the stent in my “You mean you placed the stent in my right renal artery? right renal artery?



The radiologist acknowledged this and The radiologist acknowledged this and then the patient commented in a fury “ But then the patient commented in a fury “ But you were supposed to treat the left renal you were supposed to treat the left renal artery, my right renal artery is not artery, my right renal artery is not functioning”. functioning”.

The patient then refused any further The patient then refused any further treatment and signed himself out of the treatment and signed himself out of the hospital.hospital.




The stent was placed in the wrong renal The stent was placed in the wrong renal artery artery Left kidney renal insufficiency was left Left kidney renal insufficiency was left untreated, resulting in inability to untreated, resulting in inability to perform perform its functionits function




Patients medical record not reviewed prior Patients medical record not reviewed prior to procedureto procedure

Failure to follow site verification processFailure to follow site verification process

Prior images were not reviewed prior to the Prior images were not reviewed prior to the procedureprocedure




RE – Radiology effectsRE – Radiology effects Left renal artery stenosis left untreated Left renal artery stenosis left untreated (PE)(PE) Patient inconvenience and loss of patient Patient inconvenience and loss of patient

confidence confidence (PE)(PE) Patient exposed to unnecessary radiation and Patient exposed to unnecessary radiation and

invasive procedure invasive procedure (PE)(PE) Interruption and delay in treatment of life Interruption and delay in treatment of life

threatening condition threatening condition (PE)(PE)




RE – Radiology effectsRE – Radiology effects Litigation issue Litigation issue (HE & RE)(HE & RE) Patient care issue Patient care issue (HE & RE)(HE & RE) Compliance and billing issue Compliance and billing issue (HE)(HE) Cause of sentinel event Cause of sentinel event (RE)(RE) Bad publicity Bad publicity (HE)(HE) High risk of morbidity and mortality High risk of morbidity and mortality (HE, RE & PE)(HE, RE & PE)



CountermeasuresCountermeasures

All available documentation needs to be All available documentation needs to be reviewed including prior medical imagingreviewed including prior medical imaging The time out should be followed accurately – The time out should be followed accurately – “Technologist did not speak up in this case” – “Technologist did not speak up in this case” – If If there is any question on the part of any there is any question on the part of any participating personnel, everything must stop participating personnel, everything must stop until discrepancies are sorted outuntil discrepancies are sorted out



QuestionsQuestions Whose responsibility was it to speak up during Whose responsibility was it to speak up during

team pause?team pause?

1.1. RadiologistRadiologist

2.2. FellowFellow

3.3. TechnologistTechnologist

4.4. RNRN


National Patient Safety Goals National Patient Safety Goals 2004 - 20052004 - 2005

Goal # 1 - Improve the accuracy of patient Goal # 1 - Improve the accuracy of patient identificationidentification

- - Use at least two patient identifiers (neither to Use at least two patient identifiers (neither to be the patient’s room number) whenever be the patient’s room number) whenever administering medications or blood administering medications or blood products; taking blood samples and other products; taking blood samples and other specimens for clinical testing or providing specimens for clinical testing or providing any other treatments or procedures (Scored any other treatments or procedures (Scored at PC.5.10, EP 4)at PC.5.10, EP 4)


Goal # 4 - Eliminate wrong-site, wrong-Goal # 4 - Eliminate wrong-site, wrong-patient, wrong-procedure surgerypatient, wrong-procedure surgery

- Use a pre-op verification process, such as a - Use a pre-op verification process, such as a checklist, to confirm appropriate documents checklist, to confirm appropriate documents are availableare available

- Implement a process to mark the surgical site - Implement a process to mark the surgical site and involve the patient in the processand involve the patient in the process



Provisions of the Universal ProtocolProvisions of the Universal Protocol

- Preoperative verification process- Preoperative verification process Relevant pre-op tasks completed and Relevant pre-op tasks completed and

information is available and correctinformation is available and correct

- Surgical site marking- Surgical site marking Unambiguous mark, visible after prep & Unambiguous mark, visible after prep &

drapedrape Right/left, multiple structures or levelsRight/left, multiple structures or levels



Provisions of the Universal ProtocolProvisions of the Universal Protocol

-“Time out” immediately before starting-“Time out” immediately before starting Involves entire team; active communicationInvolves entire team; active communication Fail-safe model: “No go” unless all agreeFail-safe model: “No go” unless all agree

- Applicable to invasive procedures in all settings- Applicable to invasive procedures in all settings


copyright 2005 partners radiology patient safety training “error free patient & site...

Documents

partners radiology goal

partners radiology objectives

partners radiology case

interventional radiology

sentinel events

adverse events

effects of sentinel

highrisk events