Patient Safety and Medical Error

Holly J. Humphrey, MD

Dean for Medical Education

The University of Chicago Pritzker School of Medicine

The Institute of Medicine Quality Initiative

• To Err Is Human: Building a Safer Health System (Released November, 1999)

• Impact?– Awareness– Regulation– Reporting Systems– Information Technology

• Recognition that medical errors are not usually the fault of a single person but are usually the result of flawed systems (Leape, Berwick, JAMA, 2005).

The Physician Charter

Published by the ABIM Foundation, American College of Physiciansand European Federation of Internal Medicine in 2001. Ten professional commitments, including:

Commitment to honesty with patients “Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust.”

Commitment to improving quality of care“Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error.”

ABIMF, ACP, EFIM 2001

Barriers to Change• Threat to physician autonomy and

authority

• Fear of malpractice liability)

• Complexity of health system (mix of specialties, subspecialties, & allied health professionals, reimbursement issues)

• Lack of leadership

• Scarcity of measures to gauge progress

Leape, Berwick, JAMA, 2005

Intrinsic Challenge of Medical Education

Educational needs of

learners who require

increasing independence

Safety needs of patients who benefit when

being cared for by the most experienced

physician available

Ludmerer, Johns, JAMA, 2005

Patient Safety and Medical Education

PATIENTS

STUDENTS FACULTY

Interprofessional Teams Information Systems

Lifelong Learning

SYSTEMS

FOCUS

Humphrey, JGIM, 2005

Example

The University of Chicago

“Hand-Off” Clinical Experience

Recent focus on “Hand-Offs”

• July 2003– ACGME set limits for resident duty hours– Reduce sleep deprivation and improve

patient safety

• Unintended consequence is increase in number of hand-offs

• Safety of hand-off– Error-prone – Variable– Vulnerable “gap” in patient care

Patient Safety and Medical Education

Health Care Quality

The Health Care System

The Physician

Teaching “Hand-Offs” 90-minute interactive workshop on effective hand-off strategies

Objective Simulated Hand-Off Experience (OSHE) performed 7 days after initial workshop

Students evaluated pre- and post-intervention

Teaching “Hand-Offs”• Complete written sign-out

• Verbally “hand-off” patient and sign-out to standardized resident receiver

• Underwent one hour training on hand-off expectations using the case and anticipated trigger “interval” events

• Feedback facilitated using “Hand-off CEX”– Domains assessed were organization/efficiency,

communication skill, clinical judgment, professionalism

• Debriefing after OSHE

Teaching “Hand-Offs”Results:• Statistically significant improvement in preparedness for

performing effective hand-off – 12% pre vs. 50% post reporting “well-prepared” (p<0.012)

Student Comments:• Unanimously positive experience:

– “a must have, a great experience!” – “probably the MOST USEFUL of all topics, definitely under-

taught”

• Felt realistic due to actual resident evaluators • Wanted training for additional scenarios

– Practice “sending” and “receiving” hand-off

Conclusions

• Feasible interactive mechanism to provide students with ability to practice handoff communication

• Well-received by both students and resident receivers

• Has potential for future evaluative purposes

Patient Safety and Medical Education

Health Care Quality

The Health Care System

The Physician