August 5 2014

VCU INTERNAL MEDICINE

MORBIDITY AND MORTALITY

https://www.youtube.com/watch?v=xsy5Jr3y8LA

PATIENT SAFETY

To discuss medical errors leading to adverse events in a systems based fashion.

To increase understanding of the errors that occur in medicine on an individual level.

To educate on when and how to disclose medical errors to patients.

To discuss medical error in the medico-legal context including steps which can reduce the chance of malpractice.

To create projects for risk reduction and error prevention.

Ethan Cumbler, MDMedEd Portal

WHAT IS AN ADVERSE EVENT?

ADVERSE EVENT

An unintentional, definable injury resulted from a medical intervention (ie not from the disease process.)

WHAT IS A MEDICAL ERROR ?

MEDICAL ERROR

Failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning.)

Reason, 1990 Human Error

SYSTEMS THINKING

Errors in thinking have been recognized by the field of cognitive psychology to be a product of normally adaptive mental processes thus will occur in predictable circumstances

Recognize that errors which occur at the “sharp end” are a frequently influenced by pressures remote from the final accident.

Typically for an adverse event to occur as a result of an error multiple mistakes need to have happened at different levels of the system. Many of these are “latent errors” which have been present for some time.

Good systems reduce the possibility of individual mistakes leading to harm “forced function”

REDUNDANCY

Remember that redundancy alone does not create safety.

In “An Experimental Study in Nurse-Physician Relationships” 22 nurses received a call from an unknown doctor with an order to give 20mg of “Astrogen” immediately so it would have taken effect by his arrival. The label on the bottle indicated 10mg was the maximum dose. How many gave the drug?

ANSWER

21 out of the 22 nurses gave the twice maximum dose as ordered.

Is that a product of the 1960s…. or does this still happen?

HOW CAN WE ANALYZE MEDIAL ERROR WITH A NEW FOCUS ON SYSTEMS?

Each M&M will incorporate small didactic features focused on one of the elements surrounding medical error Systems Cognitive Errors and Heuristics Root Cause Analysis Disclosure and Apology

1. Adverse event? Medical Error? Causation?2. Did Systems Errors contribute? Which

types?3. Did Individual or Cognitive Errors

contribute? Which types?4. List Heuristic Failures leading to

Individual Errors5. What level of harm came to the patient? 6. What would you disclose?

6 STEPS TO CASE ANALYSIS

Discuss systems and individual issues creating barriers to delivery of patient care

Help improve patient care

Not to place blame or say who was at fault

If you were involved with this case, please do not state your involvement in the case

GOALS

Identify a case where there was a bad outcome, perhaps related to systems issues or human error.

Review the case.Break into groups

Small group brainstorm – why did things go wrong?

Small groups present their findings in a large group discussion.Important to leave with root causes and possible solutions

FORMAT

Level of care assignment at the VAEscalation MICU consultation at the VA

KEY ISSUES

64 yo VeteranPMHx of ETOH abuse and ETOH cirrhosis1 day hx of dizziness and multiple falls, esp

when going from seated to standing position

Has fallen 7-8 times but denies LOCNo fevers, chills, nausea, vomiting, or

hematemesisDenies melena or hematocheziaPoor po intake

HISTORY – ADMIT NOTE

No increasing abd girth but does note aching over RLQ

Wife notes increasing confusionHas been prescribed diuretics and

lactulose but does not take themContinues to drink- last drink on

morning of admission

HISTORY – ADMIT NOTE

PMHxAlcohol abuseAlcoholic cirrhosisTobacco abuse Chronic sinusitisKnee painAnemia- folic acid deficiency

Meds– not takingFurosemide 20mg daily

Omeprazole 20mg po daily

HISTORY- PMHX, MEDS

SHx:Retired lawyerLives with wifeSmokes pipesDrinks 3-6oz Irish whisky dailyDenies illicit drugs

FHx:none

HISTORY- SHX, FHX

PE: VS –BP 78/50 99/71 after 2L IVF, P 80, R 17, T 97 Gen- NAD, lying in bed HEENT- anicteric, PERRL, EOMI, spider angiomata on

forehead CV- regular rhythm, nl S1S2, no S3S4, III/VI holosystolic

murmur at LLSB rad to axilla, no rub or gallop Pulmo- non-labored. Mild gynecomastia. Abd – soft, nl BS, NTND, no fluid wave. Pt refused rectal MSK- No edema. FROM. No joint swelling Neuro – AAO x 4. No asterixis. Dysmetria. Abnl finger to

nose Psych – flat affect, cooperative

PE ON ADMISSION

Na 143, K 3.9,Cl 109, CO2 14, BUN 15/cr 1.78Hgb 7.2 (MCV 90), WBC 8.7, Plt 162 (prev

Hgb 12-13)Alb 2.6, AST 190, ALT 43, ALP 104, TB 1.6CPK 111INR 2.0Lactate 10.2LDH389, haptoglobin 30.7Head CT- no intracranial hemorrhage or

mass. Moderate generalized cortical atrophy.

ADMIT LABS, STUDIES

Hypotension- ddx includes sepsis vs GI bleed vs dehydration vs adrenal insufficiency. Less likely but still in ddx includes PE, decompensated cirrhosis or valvulopathy.UA, CXR and blood and urine cx UDSAm cortisolTTESerial CBC, type and screen, transfuse if <7

A/P

Anion-gap metabolic acidosis– likely from lactic acidosis from hypotension IVFTrend lactate

AKI- prerenal vs ATN secondary to hypotension IVF, UA and urine cx pending

Acute on chronic anemia- Hgb 7.2 from baseline 12. Evidence of hemolysis (high LDH, low normal haptoglobin, evidence of schistocytes on smear.) Hx of stage 1 varices but no description of bleedSerial CBC, type and screen, start PPI

A/P - ADMIT

Falls- likely from hypotension- IVFETOH abuse- CIWA scoring, prn ativanCirrhosis- MELD 21

A/P - ADMIT

“…did fall on left side and has large abd/flank bruise. No fevers, chills, chest pain, seizure activity. Initially hypotensive but improved with 3.5L fluids and receiving 2u PRBC.On exam…bruise on left flank. Abdomen obese but not distended, no fluid wave. Another bruise noted on left lateral thigh but has good ROM and strength. FOBT neg but minimal stool in vault so poor sample.”

RESIDENT ADDENDUM

“Hgb dropped to 5.7 with fluid resuscitation. Lactate improving- 10.2 8.9.

Will consult GI for possible EGD, keep NPO. IV pantoprazole

RESIDENT ADDENDUM

New, moderate-sized intermediate density hemorrhagic ascites in perihepatic, perisplenic and paracolic gutter

Diffuse mesenteric strandingMild lobulation at tip of spleen suggesting

source of bleed is from left flank. Spleen most likely source of the bleeding which may or may not have already stopped.

Splenic and mesenteric varices

ABD CT

Gen surg consulted- correct coagulopathy, transfuse, stat CTA…”May require transfer to MCV for management of traumatic injuries if CTA reveals significant pathology.”

Gen med attending-Grey Turner’s sign on abdomen…Lipase 500 but pt has no nausea or vomiting to go along with dx of hemorrhagic pancreatitis.

MICU consulted and pt transferred

DAY 2

DDx- spontaneous retroperitoneal bleed vs traumatic bleed from falls

8 day hospital courseRepeat CT- progression of abdominal

hemorrhagic ascitesDeveloped increased abd distension, tense

ascites with decreased urine output. Concern for abdominal compartment syndrome

Paracentesis performed (5.5L hemorrhagic ascites) to relieve pressure

HOSPITAL COURSE

Multiple angiographies not able to locate source of bleed

Gen surg- Not candidate for ex lap as pt with high risk for intraoperative mortality

14u PRBC, 12U FFP, 1 dose cryoprecipitate

Hepatology – not candidate for TIPS, management options limited

Discharged to home with home hospice

HOSPITAL COURSE

SMALL GROUP DISCUSSIONS

Modified Root Cause Analysis

Level of care assignment at the VAEscalation MICU consultation at the VA

KEY ISSUES

1. Adverse event? Medical Error? Causation?2. Did Systems Errors contribute? Which

types?3. Did Individual or Cognitive Errors

contribute? Which types?4. List Heuristic Failures leading to

Individual Errors5. What level of harm came to the patient? 6. What would you disclose?

6 STEPS TO CASE ANALYSIS

LARGE GROUP DISCUSSION

Was there a medical error in the adverse event that occurred in today’s discussion? Was that error preventable?

What were the health system forces that contributed to the error? How can those systems be changed to prevent a similar adverse event from occurring in the future?

LARGE GROUP DISCUSSION

Was there a cognitive error that contributed to the error? How would you address the cognitive error?

Please recommend one course of action that our institution can take to prevent an event like this in the future. Who else should be involved in this process? What would be the role of the residents and students?