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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."
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.”
The National Patient Safety Foundation recommends that patients make sure that all of their doctors know about every medicine they are taking.
byMichael 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.
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.
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.
We had a lot on our to-do list this year. As you know from your own work, there’s no downtime when it comes to patient safety. There’s much more that can be done, but we’re excited to share a few moments from 2016 that we’re especially proud of.
As we move into 2017 and take a look at just a few (out of many) memorable NPSF patient safety achievements this year, we hope it will inspire and give you some ideas to keep moving forward in making health care safer for everyone.
NPSF began offering several complimentary Ask Me 3 resources in an effort to help in the promotion of health communication and to encourage patients to ask questions. Take a look at the materials.
We kicked off the United for Patient Safety Campaign and celebrated Patient Safety Awareness Week, designed to spark dialogue and promote action to improve the safety of the health care system for patients and the workforce. In conjunction with this week, we held a webcast entitled Safety Is a Public Health Issue with top leaders from the CDC, CMS, and AHRQ. Listen here.
NPSF President and CEO Dr. Tejal Gandhi was named to the Modern Healthcare magazine’s 2016 list of the 50 Most Influential Physician Executives and Leaders. Here's the list.
NPSF President and CEO Dr. Tejal Gandhi and COO and Senior Vice President Patricia McGaffigan collaborated on a piece published in STAT on how long shifts affect both patients and residents. In addition, we introduced the ASPPS Member Spotlight monthly series. Each month we interview one ASPPS member about their thoughts on patient safety to share with you all. If you missed any, find the series here.
The second edition of the NPSF Online Patient Safety Curriculum was released, which provides a history of the patient safety field, presents current best practices, and outlines strategies for overcoming barriers to safe care. We also rolled out our first annual Member Appreciation Month with promotions for American Society of Professionals in Patient Safety (ASPPS) members. Last but not least, NPSF President and CEO Dr. Tejal Gandhi, Bob Wachter, MD, NPSF Lucian Leape Institute member, and Gary Kaplan, MD, FACMPE, Chair,NPSF Board of Directorsmade the list of100 Most Influential People in Healthcare by Modern Healthcare magazine.
We hosted the NPSF Lucian Leape Institute Forum & Keynote Dinner in Boston with keynote speakers Charles Vincent, M Phil, PhD and Pamela F. Cipriano, PhD, RN, NEA-BC, FAAN. If you missed it, here’s a recap.
A perspective piece by NPSF President and CEO Dr. Tejal Gandhi was published in the New England Journal of Medicine on lessons learned from recent events at the National Institutes of Health Clinical Center. Also, in the spirit of giving thanks, we recognized your efforts with this video (at right).
By the end of 2016, we reached nearly 1,500 health professionals who now hold the Certified Professional in Patient Safety (CPPS) credential. Will you join them in the new year?
Caring for patients and for each other today unfortunately must also include understanding the potential harm to patients and staff safety associated with the sad reality of violence in our workplaces.
Many of us in health care have witnessed or experienced workplace violence firsthand. Workers in health care are five times more likely to be victims of nonfatal assaults or violent acts than the average worker in all other occupations, according to the Bureau of Labor Statistics. It is critical, therefore, for those in the health care community to receive key resources to help them prepare for and address, as well as hopefully prevent, violent situations from taking place.
The Joint Commission recently introduced
a virtual workforce violence resource center
to help health care organizations deal with
this very important problem.
Health care staff come to their employment settings each shift expecting to help patients. Few physicians, nurses, or other health professionals would anticipate having to deal with the increasing episodes of violence spilling over from our communities into our hospitals, ambulatory centers, and other health care locations. Indeed these incidences can hurt or kill patients, staff, and visitors. “Active shooter” situations have become another important component of emergency management preparedness.
What can health care staff and leaders do to help prevent violence and mitigate the impact? One thing is to seek out education about the issue and potential solutions. The Joint Commission recently introduced a virtual Workforce Violence Resource Center to help health care organizations deal with this very important problem. This portal, which is free and open to all, contains links to articles and research, “From the Field” case studies, and links to federal and state agencies that address workplace violence.
The high reliability concept of "mindfulness” is an apt description of the vigilance needed to notice anything unusual or something that just "feels wrong” as you go about patient care. That intuition, coupled with education on how to de-escalate crisis situations and limit damage, can save lives.
Does your organization have formal plans for addressing or preventing workplace violence? Comment on this post below. Note: to post a comment you must be logged in. Register or log in.
Ann Scott Blouin, PhD, RN, FACHE, is executive vice president, Customer Relations, at The Joint Commission. She serves on the National Patient Safety Foundation's Board of Directors and is a lifetime member of the American Society of Professionals in Patient Safety at NPSF. Contact her at firstname.lastname@example.org.
clinical pharmacy specialist in medication safety, Kaiser Permanente Colorado
Why did you join the ASPPS?
“I joined ASPPS to be part of a larger, multidisciplinary community of people who are passionate about improving patient safety. I wanted to build relationships with people who have the same interests. In addition to being part of a larger safety community, I wanted to join an organization that would help me stay informed about the most important patient safety topics, and I aspired to contribute to the advancement of patient safety initiatives.”
"We must teach the science of safety to our colleagues
and trainees and then foster their interest in the field."
What are some of the unique challenges in the field of medication safety?
“The medication use process involves many steps including prescribing, verification, dispensing, administration, education, monitoring, and reconciliation. Because it is so complicated and touched by so many people, there are many chances for an error to occur.
I am concerned that most community pharmacies do not have easy access to important health information included in electronic medical records. Pharmacists need to know information about illnesses such as concomitant diseases. For example, if a pharmacist is dispensing a prescription for a medication that is eliminated by the kidneys, the pharmacist should have access to the patient’s most recent kidney function tests to check that the dose is appropriate. In addition, they need access to lab results and procedure results to determine if a drug therapy is appropriate for a patient.
To help with this, we need an interoperability policy—the ability of different information technology systems to communicate and exchange data— that considers the sharing of pertinent health information to pharmacists who are responsible for evaluating appropriateness of drug therapy for individuals.”
In your opinion, what’s the future of the patient safety field?
“The patient safety field will prosper through partnering with colleagues who are actively practicing in clinical roles. We must teach the science of safety to our colleagues and trainees and then foster their interest in the field. If we help clinicians make a difference in their work environment, they will be strong advocates in the future and in other venues, even without having the title of safety professional. Those partnerships are critical to moving patient safety initiatives forward.”
What is something most people don’t know about you?
“One of my favorite activities is to work with clay. I like the challenge of envisioning what I intend to create with a lump of clay and then making it happen. I continually analyze my pieces to learn from my mistakes, and I try to have the same learning attitude in my professional life.”