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Sleep Deprivation, Health Care Providers, and Patient Safety

Posted By Administration, Friday, February 17, 2017

Fatigue can compromise the safety of patients and the health care workforce.


by Joanna Carmona



Christopher
Landrigan, MD, MPH

 

Medical residents working shifts of 24 hours or more make 36% more serious medical errors than those who are limited to working 16 consecutive hours, according to a 2004 study published in the New England Journal of Medicine.


Even with patient and physician safety in jeopardy over sleep deprivation and fatigue, there’s still much debate over reducing trainees’ hours. Some of the objection to duty hour limits comes from the idea that trainees need to work extra hours in order to gain clinical experience and that shorter shifts may cause harm due to the increased handoffs required.


To Christopher P. Landrigan, MD, MPH, research director of the Inpatient Pediatrics Service at Boston Children’s Hospital, director of the Sleep and Patient Safety Program at Brigham and Women’s Hospital, and associate professor of pediatrics and medicine at Harvard Medical School, however, the misunderstanding of this key issue is the jumping off point to start discussion and change.


In a 2013 interview in PSNet, Dr. Landrigan said that “the trick is to implement changes in work hours in concert with concentrated efforts to improve the handoff process, teamwork, and infrastructure. Doing so can address fatigue-related errors without necessarily leading to a substantial increase in handoff errors. The net result can indeed be one where fatigue-related errors are reduced and handoff errors are not increased either.”


   
   

Dr. Landrigan has a wealth of experience on this topic and is the featured speaker for the National Patient Safety Foundation’s next Professional Learning Series Webcast, Sleep Deprivation, Health Care Providers, and Patient Safety, on February 27, 2017. He has led numerous landmark studies on the epidemiology of medical errors and adverse events, and interventions designed to reduce their incidence. His most important work has been focused on developing reliable patient safety measurement tools, and improving the organization of residency programs and academic medical centers. Dr. Landrigan’s work has contributed to national changes in resident work hour standards.


In 2011, the Accreditation Council for Graduate Medical Education (ACGME) created a set of requirements stating that duty periods of PGY-1 (Post Graduate Year One) residents must not exceed 16 hours in duration. Most recently, however, ACGME is in the midst of a re-review of the requirements with the intention of deciding whether or not to revert these requirements, allowing PGY-1 residents to take on 28-hour shifts like their more senior colleagues.


We know that when restrictions on shift hours are put in place, residents report that their quality of life improves and the rate of serious medical errors is reduced. We’ll discuss this and much more on the relationship between health care provider work hours, sleep deprivation, and patient safety. Please join us for this timely discussion.

 

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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at jcarmona@npsf.org.

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Tags:  fatigue  medical education 

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Member Spotlight: Adrian White

Posted By Joanna Carmona, Thursday, February 2, 2017
Updated: Thursday, February 2, 2017

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles. 


by Joanna Carmona 

Adrian White
   

Adrian White is a member of ASPPS

 

Adrian White, RN, MBA, CPPS, Ambulatory Safety Outcomes and Performance Improvement Director

University of Texas Southwestern Medical Center

What are the biggest patient safety challenges you face at the University of Texas Southwestern Medical Center?

“The greatest challenge I face in my role at UT Southwestern is understanding the diversity of services we offer on our campus. Like many other academic medical centers, we deliver an array of services with various requirements from a regulatory and accreditation perspective. Outpatient and ambulatory areas are a melting pot for this diversity, resulting in slightly different ways of doing things in clinics that are on the same floor, or even share the same waiting area, but fall under a different governance structure.  

 

"While safety is a common thread in all of these areas, we need to ensure that a level of consistency exists in our practices. To address these challenges, a group within our organization, representing a wide variety of key stakeholders, spent six months creating a strategy document to build a comprehensive safety plan with a focus in the ambulatory and outpatient areas. While we recognize how different each department is, it is important for us to ensure that we are all connected and working collaboratively.”

 

"We need to have an openness of mind and heart that errors occur, despite our best intentions."

—Adrian White

Tell us why you chose to become a member of ASPPS?

“I wanted to become a member of an organization with a tried-and-tested history in patient safety. NPSF has its finger on the safety pulse, and the resources it provides helped me from a practical viewpoint in framing our outpatient safety plan.

 

"It also allows you the opportunity to build a support network of safety professionals around you. I have used the NPSF message boards to ask patient safety questions and I’ve had multiple people respond, many of whom lived through the same situation and have the bruises to show for it. Instead of reinventing the wheel, these colleagues have given me something to consider and adopt to my own situation.”

What made you interested in joining the patient safety field?

“The first stems back to my nurse training. One of my best friends through nursing school was involved with a medical error while we worked together in orthopedics. How everything was handled after the incident occurred really upset me, and our group. There was a lot of finger pointing and blame, when, in fact, there were multiple processes that weren’t followed. For weeks I wondered ‘where were the stop gaps to prevent us, mere students, from falling into traps.’ It was a positive outcome in the end, but the incident really stuck with me.

 

"Fast forward a few years and at 24 I became a nurse manager in Ireland who thought he knew everything. But I made a drastic medication error, too. The patient was fine in the end, but my actions could have killed him. This made me realize that an overdose of self-confidence will set you up for failure, and your world can come crumbling down at any moment with potentially disastrous consequences. These two personal experiences made me think: What is patient safety all about? Since then, the investigator in me is always asking ‘how’ and ‘why,’ and safety issues have plenty of answers to share.”

 

What keeps you up at night?

“When you talk with colleagues about a safety issue and they respond with: ‘That wouldn’t happen in my area’ or ‘Why would someone in their right mind do that?’, that apathy or arrogance worries me. We are all flawed individuals, and things will happen. We need to have an openness of mind and heart that errors occur, despite our best intentions.

 

"I also worry that people are afraid to speak up. When a safety event happens here at my institution, I want people to know that we should talk about it. I want them to hear someone say ‘You’ve done the right thing by reporting this issue. We just want to know what happened and to discuss ways to ensure that it won’t happen again.’ Having that openness and willingness to discuss these issues will make patients safer in the future.”

 

What is something unique about you?

“I am an immigrant. I came to the US from Ireland in 2008. My upbringing in Ireland and my training as a nurse in a very different health care system has helped me bring a diverse lens in reviewing issues I encounter working here in the US. Also, I have learned that my ‘brogue’ is a very powerful tool, and quite often my colleagues ask ‘How did you get away with saying that?’”

 

 

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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at jcarmona@npsf.org.

 

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Tags:  ASPPS Member Spotlight 

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Making Quality and Safety a Priority in Health Care for Our Children

Posted By Administration, Thursday, January 26, 2017
Updated: Thursday, January 19, 2017

New journal seeks to disseminate results of pediatric quality and safety work 

The first to focus solely on improving the medical systems that care for our most precious resource: our infants and children.


by Richard J. Brilli, MD, FAAP, MCCM


   

Dr. Richard Brilli

 

When the first medical journal was published in the United States, doctors were still debating the merits of bloodletting, anesthesia was an emerging concept, and the stethoscope had not yet been invented. By today’s standards, of course, medicine back then was still very primitive and physicians relied more on instinct in their practices than on collective knowledge.

In January of 1812, that began to change. That month, the first issue of the New England Journal of Medicine was published, and in its opening paragraph, editor Dr. John Warren called on doctors to be “directed by a knowledge of preceding discoveries.” Instead of practicing medicine as individuals, the publication encouraged doctors to document their experiences and share that information.

It was a milestone in American medicine. Publishing their experiences allowed physicians and researchers to accumulate knowledge, step-by-step, across a vast array of conditions. Soon, other journals were founded that focused on specific diseases and conditions. Now, more than two centuries later, we take another small but important step along that journey.

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Last fall, I was privileged to help launch the journal Pediatric Quality and Safety. While most peer-reviewed medical journals since the early 19th century have focused on disease, this is the first to focus solely on improving the medical systems that care for our most precious resource: our infants and children. Quality improvement (QI) was once only a peripheral concern for many organizations, but the time has come to make it a priority in pediatrics.

Though QI science has been maturing over the past few decades, it became apparent to me, as chief medical officer at Nationwide Children’s Hospital, that the pediatric perspective is unique. The mechanisms and types of injuries and preventable harm that children suffer while being cared for in the hospital, such as surgical-site infections and adverse drug events, are often different from those seen in adult care.

In an effort to address those pediatric-specific issues, our team at Nationwide Children’s Hospital developed an initiative called Zero Hero. The idea was simple: we needed to not only lower the rate of preventable harm and injuries in the children we care for, we needed to strive for zero instances.

The idea caught on, and in 2009 all 8 children’s hospitals in Ohio joined together to form a collaborative called the Ohio Children’s Hospitals Solutions for Patient Safety. Together, we followed the lead of Dr. Warren, freely sharing information about our experiences and openly debating and establishing best practices. Within the first few years, using QI science methodology, we attained considerable success in lowering preventable harm rates.

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So successful were we that the concept has gone national. Today, more than 100 children’s hospitals across the country have joined our initiative, working to eliminate 10 hospital-acquired conditions, including adverse drug events, catheter-associated urinary tract infections, central line–associated bloodstream infections, pressure ulcers, and ventilator-associated pneumonia, among others.

Since 2012, through May of 2016, the Solutions for Patient Safety Collaborative has saved 6,686 children from serious, preventable harm, which has led to an estimated savings of more than $121 million dollars in medical costs. That’s an average of saving more than 4 children from harm and more than $76,000 in costs every day, with a consistent upward trend each month.

We still have work to do, which is where this new journal will play a key role. As children’s hospitals everywhere strive to develop and deliver quality, evidence-based care, the journal will provide a perfect vehicle for collaboration. We will be able to collect and concentrate data and information from all over the world in one place, where it can be freely shared, easily disseminated, and rigorously debated.

It was this approach that proved so effective for Dr. Warren more than 200 years ago, and it’s time we dedicate the same focused efforts to safe and quality care for our children.

 


--------------------------------------------
Pediatric Quality and Safety (PQS) is an international, peer-reviewed, open-access, online periodical that publishes results of quality improvement and patient safety initiatives that impact the lives of children. For details about submitting a manuscript visit the website.

 

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Richard J. Brilli, MD, FAAP, MCCM, is co-editor-in-chief of the journal Pediatric Quality and Safety and Chief Medical Officer at Nationwide Children’s Hospital in Columbus, Ohio.

 

Tags:  children's hospitals  patient safety research  pediatric safety 

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Member Spotlight: Jason Adelman

Posted By Joanna Carmona, Tuesday, January 10, 2017
Updated: Tuesday, January 10, 2017

The American Society of Professionals in Patient Safety (ASPPS) is a membership program for professionals

and others interested in patient safety. This is part of a series of member profiles. 


by Joanna Carmona 


   

Jason Adelman is a lifetime member
of  ASPPS

 

Jason Adelman MD, MS, Chief Patient Safety Officer, Associate Chief Quality Officer

Columbia University Medical Center/NewYork-Presbyterian Hospital

Board of Advisors, NPSF

 

What made you interested in joining the patient safety field?

 

“During my time as a hospitalist I became aware of the kinds of significant medical errors that can happen in a hospital. In one case of a wrong-patient error, an elderly woman was mistakenly given methadone through a series of systems lapses and ended up in a coma in the ICU. It was upsetting to hear of this error, but I also realized the potential for Health IT systems to protect patients from harm by keeping providers from making errors. This event really affected me, and further drove my interest to adapt our IT systems to reduce errors that could cause harm to patients.

 

“Given my interest in the field, when the time came for our hospital to name a patient safety officer, they approached me and I jumped at the opportunity to take on that role. There is more formal education now, but back then there were few opportunities for training in patient safety. I found my way to NPSF because it was the only patient safety organization with the focus I was looking for. I started attending and volunteering at NPSF conferences to learn as much as I could about patient safety. I’ve continued that learning in my position as chief patient safety officer and through my research into wrong-patient errors and Health IT safety. The luckiest thing in the world is to have your job not feel like a job, but be a true passion, and that’s how I feel about patient safety.” 

 

"It will be a long journey fraught with speed bumps and wrong turns, but if we keep designing and implementing safer systems,

Health IT will become as reliable as an ATM dispensing cash."

—Jason Adelman

What are some ways we can use information technology to prevent medical errors?

“I believe that eventually Health IT will make health care significantly safer and more reliable. It will be a long journey fraught with speed bumps and wrong turns, but if we keep designing and implementing safer systems, Health IT will become as reliable as an ATM dispensing cash. I believe Health IT will ultimately prevent diagnostic errors, medication errors, and generally help make healthcare reliable and safe.

 

“Some of the research I’ve done over the past several years has demonstrated how technology can help reduce errors. For example, I’ve created a metric to quantify wrong patient errors by developing an IT tool that looks for when doctors place an order on a patient, cancels that same order, and then places the exact same order for another patient. We would run this report twice a day and find at least 15 to 20 instances of potential wrong-patient errors each day, and then call the doctors involved and ask them what happened. Most of the time these events were confirmed as errors. We were then able to test interventions to reduce wrong-patient errors by using this metric. (See Understanding and preventing wrong-patient electronic orders: a randomized controlled trial.)

 

“In fact, we used this system for measuring wrong-patient errors to demonstrate that hospitals who temporarily name newborns Babyboy or Babygirl significantly increase the risk of placing an order on the wrong baby in their NICUs.  However, we were also able to demonstrate that if hospitals used more distinct temporary names that incorporates the mother’s first name, such as Wendysboy or Judysgirl, they can significantly reduce this risk.  This research was only possible because we had a reliable measure of wrong-patient errors.” (See Use of Temporary Names for Newborns and Associated Risks.)

 

Why did you become a member of ASPPS?

“I am passionate about patient safety. I want to continually learn as well as to share my experiences in patient safety, with the hope to improve patient safety beyond the hospital where I work. Being a member of ASPPS is one of the ways I use to connect with people.

 

“I am currently the chief patient safety officer at Columbia University Medical Center at New York-Presbyterian Hospital. I got this job because several years ago their quality and safety leadership read my article on wrong-patient errors. They got in touch and asked how I put the system together and I gladly shared everything I knew. I wanted them to have all of the information I had, so they could help patients at their hospital. Because of this, when there was a change in leadership they thought of me. I believe that when it comes to patient safety, we should all share what we know so that each person involved in patient care can contribute to making care safer for everyone.” 

 

What is something unique about you?

 

“I have four kids so there’s always activity in my house. I can see how distractions can lead to errors. In my case, right after dinner I often join my four kids in the living room to play a game. On occasion the children and I will leave food out in the kitchen, which is annoying to my wife. It’s not a life-threatening error, but we can all use a little help dealing with distractions and human errors.” 

 

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Joanna Carmona is communications coordinator at the National Patient Safety Foundation. Contact her at jcarmona@npsf.org.

 

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When Specialist “Hop Scotch” Can Lead to Mishaps

Posted By Administration, Wednesday, December 28, 2016
Updated: Wednesday, December 28, 2016

The National Patient Safety Foundation recommends that patients make sure that all of their doctors know about every medicine they are taking. 


by Michael Kelleher, MD

  

The following is a true story that involved a close relative of mine. For the sake of argument, we’ll call him “Mr. K.”

 

Mr. K. underwent surgery for colon cancer, complicated by a prolonged recovery with poor appetite, bloating, and persistent abdominal discomfort. At the same time, he was undergoing treatment for rheumatoid arthritis. His arthritis specialist had prescribed prednisone tablets at 10mg daily. There was no communication, however, between the surgical and arthritis specialists. In addition, the primary care physician (PCP) had not yet received a rheumatology note listing the new prednisone medication.

 

"Specialists usually have no idea

who else is treating you unless you tell them."

Mr. K returned three times to the surgical office with his post-operative complaints. He was advised that infection was unlikely because he had no fever. But, Mr. K’s prednisone therapy was masking his fever and the signs of inflammation in his belly. After another week of misery at home, he took himself to the local emergency department where he was noted to have dangerously low blood pressure and a CT scan that showed a very large abdominal abscess.

 

This near-fatal delay in appropriate care was the result of poor communication among the patient's three treating physicians. This is, unfortunately, a common occurrence in our fragmented health care system. Although some large multispecialty group practices have electronic health records (EHRs) that are shared across all clinical offices, most private offices do not share a common EHR platform and do not communicate electronically with all the other clinicians who are treating you. In fact, specialists usually have no idea who else is treating you unless you tell them.

 

Download the Medication Wallet Card from NPSF or read more about medication safety on the AHRQ website.

 

Boosting communication


In this scenario, we can all agree that more than just one thing went wrong, but when it comes to medication, everyone involved in your care needs to be on the same page. The National Patient Safety Foundation, the Agency for Healthcare Research and Quality (AHRQ), and others recommend that patients make sure that all of their doctors know about every medicine they are taking. This includes prescription and over-the-counter medicines and dietary supplements.

 

Even if the medical office staff does not specifically ask for this information, provide it and ask that it be included in the specialist records. This can reduce the likelihood of an adverse event like what happened to Mr. K.

  

Other things patients can do to promote safe care:

 

Inform clinicians of all treatment plans

Take a minute to call your PCP’s office staff to inform them of any treatment plans proposed or implemented by other clinicians. In theory, the PCP will eventually receive a mailed letter from the specialist with that information, but this is not a guaranteed process, and may not happen for several weeks.

 

Update your electronic health records

Most of these EHRs include patient portals, which give patients online access to their primary care site. This is a convenient way to update your PCP’s office (without struggling to get through on the phone) regarding care that you have received elsewhere.

 

When it comes to communicating with your health care providers, never assume that they know what another clinician has ordered for you. Always share the details.

 

 

This post was adapted with permission from Avoidable Medical Mishaps: A Patient Guide.

 

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  Michael Kelleher, MD, past member of the Mass Medical Society's Quality of Medical Practice Committee, has 34 years of experience as a physician and medical executive responsible for patient safety and quality of care in large group practices.

 

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2/27/2017
Professional Learning Series Webcast: Sleep Deprivation, Health Care Providers, and Patient Safety

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