prevention of medical errors - florida osteopathic …. burns, d.o. 2016 prevention of medical...

R. Burns, D.O. 2016

Prevention Of Medical Errors

Ronald R. Burns, DO, FACOFP

Member AOA Board of Trustees Member NBOME Board of Trustees

Fellow Federation of State Medical Boards

R. Burns, D.O. 2016

CME Requirement Not all Prevention of Medical Errors courses will meet the criteria for renewal. It is important to make sure that the course you take includes the following information: a study of root-cause analysis, error reduction, prevention and patient safety and the five most misdiagnosed conditions during the previous biennium. Please remember to periodically refer to rule 64B15-13.001, F.A.C. for the specific Prevention of Medical Errors course requirements as they may change every two years.

R. Burns, D.O. 2016

Educational Objectives: Identify systems, processes and conditions that could contribute to errors in any clinical environment. Understand the study of root-cause analysis, principles of error reduction and prevention for patient safety. Discuss and document the risks, alternatives, and benefits of therapy. Recognize health care quality problems in terms of underuse, overuse and misuse.

R. Burns, D.O. 2016

456.013 Florida Statutes

The 2001 Florida Legislature established the requirement of a 2- hour course relating to prevention of medical errors as part of the license and renewal process.

R. Burns, D.O. 2016

National Patient Safety Goals

Patient identification Communications Medication safety Health care-acquired infections Reconcile medication use across continuum of care Patient falls

Presenter

Presentation Notes

Improve accuracy of patient identification – use of 2 identifiers Improve effectiveness of communication among caregivers – standardized abbreviations not to be used – read back orders/results - applies to orders and medication related documents – improve timeliness of reporting (critical test results/values) Improve medication safety– standardize & limit availability of drug concentrations --- label all meds, containers, & other solutions on & off the sterile field in perioperative and other procedural settings --- Identify and review list of look alike/sound alike drugs and take action to prevent errors involving interchange of these drugs Reduce risk of health care-acquired infections – CDC Control and Prevention hand hygiene guidelines Reconcile use of medications – obtain and document complete list of patient’s current medications – develop process for communicating list to next provider Patient Falls – assess/reassess each patient’s fall risk – implement fall reduction program

R. Burns, D.O. 2016

Identify Systems, Processes and Conditions

R. Burns, D.O. 2016

Root-Cause Analysis

R. Burns, D.O. 2016

Root Cause Analysis

Structured and process-focused framework to approach sentinel event analysis

Looks at active and latent categories of error

Primary aim: avoid culture of individual blame

Presenter

Presentation Notes

Data collection: structured interviews, document review, and/or field observation. Generate a sequence or timeline of events preceeding and following the event. Active failures are unsafe acts or omissions committed by people in direct contact with the pt. Action slips/failures – picking up wrong medication Cognitive failures – memory lapses, mistakes, true ignorance or misreading situation - forgetting to order PTT after Heparin infusion Violations – deviations from safe operating practices, procedures or standards – nurse shuts system alarm volume down – keeps going off when there is no problem Latent failures Removed from the direct control of the front line person/operator. Time pressures, poor staffing, inadequate equipment, fatigue, inexperience. Analogy: Active failures are like mosquitoes –you can swat them 1 by 1, but they keep coming. Not until you drain the swamp and remove the latent condition that breeds mosquitoes can you control the mosquitoes.

R. Burns, D.O. 2016

FDA’s MedWatch

www.fda.gov/medwatch Gateway for medical product safety information. Provides a service that sends out urgent safety alerts via e-mail. Allows voluntary reporting of adverse events. 1-800-FDA-1088

http://www.fda.gov/medwatch

R. Burns, D.O. 2016

Identify Systems, Processes and Conditions

R. Burns, D.O. 2016

Medical Error CE Rule “5 Most Misdiagnosed Conditions”

Inappropriate Prescribing of opioids Failure or delay in diagnosing Cancer Retained foreign objects in surgery and wrong site/patient surgery Surgical complications/errors and pre-operative evaluations Prescribing, dispensing, administering, or using non-FDA approved medications and devices

R. Burns, D.O. 2016

Summary Remember the 4 C’s : Charting, Communication, Compassion, Competence. Name, Blame, Shame does not work. Develop systems that help reduce error, by training, retraining and communicating. Develop a culture where monitoring and testing is the norm.

prevention of medical errors - florida osteopathic …. burns, d.o. 2016 prevention of medical...

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