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A review of two residency processes aimed at reducing medical error: A variation on the Morbidity and Mortality Conference Unusual Occurrence Reporting in the Family Medicine Residency Clinic Jessica Burness MD and Elizabeth Klein MD Providence Milwaukie Family Medicine Residency Milwaukie Oregon
Introduction of Participants
Who are you? Where are you from? What do you hope to learn? Destiny by William Bryan: Destiny is not a matter of chance, it is a matter of choice. It is not a thing to be waited for- it is a thing to be achieved. So it is with Managing Medical Error in 2008
Error Definition
IOM Failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim AAFP Past President Dr Bruce Bagley A medical error is anything that happens in my office that shouldnt have happened and I absolutely do not want to happen again
Resident vs Practicing MD
35-50 % of Resident Errors due to misdiagnosis or delay in care Practicing Physician Errors are more likely related to process errors, results lost, not acted on, lost specimen, lost or incomplete records
??? Remains- How do you implement a systematic program for error evaluation and disclosure in the family medicine office??
Culture of Safety
Empower everyone to point out errors Look for weak links Look for root causes Review and update polices and procedures Avoid punishing those who commit errors, within reason
PLANNING
Innovative Director- Dr Bill Gillanders Our faculty are adventuresome and idealistic Our program is young and willing to pilot new projects- Ex EHR, Electronic Billing, Electronic Orders, Depression Screening in the waiting room etc. We value and ask for input from staff, residents and faculty
Examples of UORs
Narcotic prescribing, lack of contracts, need for compliance by docs, especially faculty Visual acuity on every patient with eye complaint Steroid injection depigmentation- Didactic and better PARQ Form for steroid injections Missed ischemia on EKG- New form and process for EKG reporting and faculty sign off IUD Perforation- Didactic on IUD PARQ and insertion-new IUD consent form
Lessons Learned
Innovative director and enthusiastic clinic manager really helps Emphasis on improving systems to protect patients and staff is important Promotes good role modeling by faculty Empowers staff because they see results Promotes Culture of Safety
Outline
1. 2. 3. 4. 5. Background and Rationale Core Concepts for Revised Model Pilot Our Experience Future Directions
There is evidence that exposure of error in Morbidity and Mortality conferences can cause stress, anxiety and blaming which may lead to future non-disclosure of medical errors.
Wu, A., Folkman, S., McPhee, s., et al. Do House Officers Learn from their Mistakes? JAMA. 1991: 265: 2089-2094.
Core Concepts
All adverse patient outcomes should be identified on a continuous basis. Cases should be generated from the entire practice population. Error and adverse events should be classified and defined according to a basic taxonomy of error. Moderator(s) should ensure the conference environment is supportive and non-persecutory, and that it does not stray from the format.
Core Concepts
Faculty and residents should both participate in generation of cases and discussion of cases. If systems problems or generic mistakes are identified, discussion should be facilitated on how to prevent future similar adverse events. An action plan should be identified and subsequent practice changes should be communicated and implemented.
Goals
Can a Morbidity and Mortality conference be structured such that it simultaneously systematically evaluates medical error and is perceived by residents as being educational, supportive, safe and non-persecutory? Surveys before and after pilot study implementation to attempt to answer the question for this Morbidity and Mortality conference design.
Limitation
The only computerized database currently available to cull data on adverse outcomes is the inpatient database. Ideally, we would have similar ability to access data for outpatient care.
Sample Case
From selection, through presentation and discussion, to follow-up
The goals of the conference are 1. to learn from each other in a supportive environment and 2. to improve patient care in our practice.
Future Directions
Incorporating ideas from Matrix Process at Cedars Sinai Patient Healthcare Matrix Creation of system to query outpatient data for markers Greater number of cases, rely on databases, not solely volunteers Your ideas?????