Bridging the Gap in Risk Management and Patient Safety

August 18-21, 2020

Adverse Incident Reporting and the Prevention of Medical Errors

Presented by: Jacqueline R. Ambrose Root

Adverse Incident Reporting and the Prevention of Medical Errors

Jacqueline R. Ambrose Root, Esq.

Healthcare Litigation Partner

Pennington, P.A.

What is a “Medical Error”?

A medical error is a preventable adverse effect of medical care, whether or not it is evident or harmful to the patient.

Carver N, Hipskind JE. Medical Error. [Updated 2019 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019

Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430763/

Among the problems that commonly occur during providing health care are adverse drug events and

improper transfusions, misdiagnosis, under and over treatment, surgical injuries and wrong-site

surgery, suicides, restraint-related injuries or death, falls, burns, pressure ulcers, and mistaken

patient identities. High error rates with serious consequences are most likely to occur in intensive care

units, operating rooms, and emergency departments. Medical errors are also associated with

extremes of age, new procedures, urgency, and the severity of the medical condition being treated.

In the News…

Pop Quiz: What are the most common medical errors?

• adverse drug events• catheter-associated urinary tract infection (CAUTI)• central line-associated bloodstream infection (CLABSI) • injury from falls and immobility• obstetrical adverse events• pressure ulcers• surgical site infections (SSI)• venous thrombosis (blood clots)• ventilator-associated pneumonia (VAP)

Most Common Contributing Causes

• Failure to order appropriate tests and address abnormal results

• Failure to use clinical information to establish the differential diagnosis

• Patient Characteristics• Obseity

• Skipping exam elements

• Non-compliance with treatment plans and follow up appointments• Poor patient hygiene

• Communication issues among providers• Failure to communicate• Failure to review medical record• Poor professional rapport• Communication between providers and patient/family

• Non-use of qualified interpreters

• Electronic Health Records• Systemic• Individual

https://www.nejm.org/doi/full/10.1056/NEJMhle1005210?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed

COMMUNICATION AND DOCUMENTATION

CHAIN OF COMMAND CULTURE METHODS OF COMMUNICATION AND

DISCOVERABILITY

Communication

Communication and Documentation

• If it wasn’t documented…

Simple Rules (Part 1)

Just the facts,

Ma’am.

• Simple Rules: Clearly identify issues that do not belong in medical record

• Payment

• Liability

• Blame

• Insurance coverage or absence thereof

• Need for incident report or Risk involvement

Simple Rules (Part 2)

Chain of Command

• Established Procedure, Including Training

• When to Deviate

• Supportive Culture

Communication and Culture

• Medical Record

• Phone

• Text• HIPAA

Methods of Communication and Discoverability

“Well, the care was defensible, but…”

• Medical records are defense counsel’s best weapon

• Juries don’t believe recollections of providers regarding care

• Providers often don’t remember the care to begin with

• Documentation issues make the jury doubt the reliability of the rest of the medical record, which can kill our case

• Major focus of plaintiff attorney depositions

• Even if the care was perfect

• The best possible deposition preparation is good documentation

Documentation

Documentation Guidelines

• Encourage contemporaneous documentation

• As close to the care documented as practicable

• Patient care comes first

• Strongly discourage use of unnecessary, non-clinically

defined adjectives and adverbs

• Medical record documentation should be factual and

objective to the extent possible

• If a provider feels the need to make commentary…

• Talk with supervisor

• Talk with Risk

• Don’t do it in the medical record

Electronic Documentation

• Problematic drop-downs

• Lack of detail

• Conflicting entries

• Pre-populated fields

• Inherent issues with identical entries

EMR Issues: Lack of Detail, Auto-Population, Pre-populated Fields

• EMR documentation is heavily flowsheet-based

• Nurses in EMR facilities generally write fewer narrative notes

• Tendency: shorter and less detailed

• Patient care concerns

• Narrative notes are also much more reliable and believable to juries…

• Use of entire sentences support the conclusion that they actually observed/did what is documented

• Flowsheet is just a single entry, could be drop down, much easier to discount as erroneous or inaccurate entry

Documentation Best Practices

• Simple Rules

• Work with your IT and/or HIM departments

• Design drop-downs to the extent possible to exclude “impossible” options

• Make monitoring alarm values intentional

• Intervene upon identification of a problematic drop-down option

• Encourage narrative notes

• Consider eliminating or limiting auto-population

How to Prevent Medical Errors

Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer. for patients and healthcare workers

Rodziewicz TL, Hipskind JE. Medical Error Prevention. [Updated 2019 May 5]. In: StatPearls [Internet]. Treasure

Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/

How to Prevent Medical Errors

Fear of punishment makes healthcare professionals reluctant to report errors. While they fear for patients’ safety, they also dread disciplinary action, including the fear of losing their jobs if they report an incident. Unfortunately, failing to report contributes to the likelihood of serious patient harm. Many healthcare institutions have rigid policies in place which also create an adversarial environment. This can cause staff to hesitate to report an error, minimize the problem, or even fail to document the issue. These actions or lack thereof can contribute to an evolving cycle of medical errors. When these errors come to light, they can tarnish the reputation of the healthcare institution and the workers.

Florida Law: Adverse Incident Reporting

• Florida law: All hospitals must establish a risk management

program that includes the development and implementation of an

incident reporting system

• Health care providers and all hospital employees have an

affirmative duty to report adverse incidents within 3 business

days of their occurrence

• Hospitals must report adverse incidents to AHCA within 15 days

of occurrence

Defining “Adverse Incident”

What is an “adverse incident” that must be reported under state law?

• An event• over which health care personnel could exercise

control • and which is associated in whole or in part with

medical intervention (rather than the condition for which such intervention occurred)

• and which…

Defining “Adverse Incident”

…either:(a) Results in:

• death; • brain or spinal damage; • fracture or dislocation; • limitation of neurological, physical, or sensory function which continues

after discharge; • a condition that required treatment that resulted from nonemergency

medical intervention without informed consent; or • a condition that required transfer to a unit providing a more acute level of

care due to the adverse incident;

Defining “Adverse Incident”

(b) Was surgery on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgery otherwise unrelated to the patient’s diagnosis or medical condition;

(c) Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosedto the patient and documented through the informed-consent process; OR

(d) Was a procedure to remove unplanned foreign objects remaining from a surgical procedure.

Sample Event Reporting Policy(Hospital)

•“Reportable Event”: an event that is not consistent with the routine operation of the hospital or the routine care of a patient or patients

• Near misses are Reportable Events

• Reportable Events may or may not result in negative consequences to the patient

• Any medical staff member, hospital employee, agency staff, contractor, orvolunteer who witnesses, discovers, or has direct involvement in and/orknowledge of a Reportable Event must complete an Event Report

• Event Reports are to be completed using PSRS, the Patient Safety ReportingSystem

• If serious injury occurred, in addition to and separate from completing EventReport, notify Risk Management and attending physician

Patient Safety-Focused Event Reporting Culture

26

While admitted, a patient takes their normal at home pain medication. RN tells patient that this cannot happen, and has pharmacist intervene and lock up medication until discharge.

• Should an event report be filed?

Patient Safety-Focused Event Reporting Culture

27

• If a patient develops a HAPU… do we report it as an adverse incident?

Patient Safety-Focused Event Reporting Culture

28

• Patient arrives to ICU from cardiac OR with an open chest… incident report?

Patient Safety-Focused Event Reporting Culture

29

• MD intubates esophagus three times, causing gastric perforation. Pt. to OR for repair.

Patient Safety-Focused Event Reporting Culture

30

• Patient self-extubates.

Patient Safety-Focused Event Reporting Culture

31

• Patient has a stroke.

Patient Safety-Focused Event Reporting Culture

32

• A central line is inadvertently placed in an artery. Prior to accessing the line, RN noticed pulsatility, notified a pulmonary resident, resident removed the line. Patient had to return to OR for repair to laceration of artery.

Patient Safety-Focused Event Reporting Culture

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• Is this routine patient care?• If not → create an Event Report

• Unsure if a report is needed?• Call Risk Management

How to Prevent Medical Errors

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• All providers (nurses, pharmacists and physicians) must accept the inherent issues in their roles as healthcare workers that contribute to error-prone environments.

• Effective communication related to medical errors may foster autonomy and ultimately improve patient safety.• Error reporting better serves patients and providers by mitigating their effects.• Even the best clinicians make mistakes, and every practitioner should be encouraged to provide peer support to their

colleagues after an adverse event occurs.Medical errors and near misses should be reported when they are discovered. Healthcare professionals are usually the first tonotice a change in a patient's condition that suggests an adverse event. A cultural approach in which personal accountability results in long-term increased reporting reduces errors.

Rodziewicz TL, Hipskind JE. Medical Error Prevention. [Updated 2019 May 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-

. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499956/

Jacqueline R. Ambrose Root, Esq.Healthcare Litigation Partner

Pennington, P.A.

jroot@penningtonlaw.com(813) 549-4146

Questions?