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Prevention of Medical Errors FS 456 013(7)FS 456.013(7)
Florida Chapter of American College of PhysiciansSt. Petersburg Beach, Florida
October 5, 2013
Cliff Rapp, LHRMRegional Vice President Patient Safety
Course Objectives
At the conclusion of this presentation, participants will be able to:participants will be able to: Recognize medical error reduction and
prevention strategiesprevention strategies
Describe a root cause analysis
Identify patient safety goals Identify patient safety goals
Recite the most “misdiagnosed” conditions
M t th i t f FS 456 013(7) Meet the requirements of FS 456.013(7)
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Medical Malpractice vs. Medical Error
Average indemnity payment–$331,947(1)
Average defense costs are rising at a faster rate than average indemnity payment(1)(2)
Approximately 25 percent of non-meritorious claims are paid(1)
In Florida 57 percent of claims are closed with indemnity(3)
(1) PIAA Risk Management Review 2011 Edition(2) PIAA Risk Management Review 2009 Edition(3) FOIR 2011 A l R t 10 1 11
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(3) FOIR 2011 Annual Report 10.1.11
Internal Medicine – National Loss Data
$350,000
$400,000
$200 000
$250,000
$300,000
Avg Indemnity Paid
$100,000
$150,000
$200,000 Avg. ALAE PAID Clms
Trendline
$‐
$50,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
PIAA Risk Management Review 2012 Edition
Average Indemnity Payment - $338,474 Average ALAE - $75,487
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PIAA Risk Management Review 2012 Edition
National Loss Data – Internal Medicine
Most Prevalent Patient Conditions
• Chest Pain $322,688Symptoms involving pelvis• Symptoms involving pelvisand abdomen $764,906
• Pneumonia $150 000Pneumonia $150,000• Acute myocardia infarction $615,530• Renal failure $305,312
PIAA Risk Management Review – 2012 edition
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PIAA Risk Management Review – 2012 edition
National Loss Data – Internal Medicine
Most Prevalent Misadventures
• Diagnostic Error $451,126• Failure to Supervise/Monitor $175,527• Medication Errors $174,702• FTD/DID Complication $307,304
F il /D l i R f l• Failure/Delay in Referral or Consultation $313,528
PIAA Risk Management Review 2012 edition
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PIAA Risk Management Review – 2012 edition
Hospital Medicine – Inherent Risk Factors
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RCA
• Communication breakdowns are causative factors in 65% 80% of claimsfactors in 65% - 80% of claims
• 25% of diagnosis-related malpractice claims are due to a failure to follow-up
- diagnostic studies- clinical status
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RCA of Medical Errors
Communication factorsU l li f th it Unclear lines of authority
Highly variable physical settings Varied healthcare processes Varied healthcare processes Time pressured environment System deficiencies System deficiencies Vulnerable defense barriers Human fallibilityHuman fallibility
National Patient Safety Foundation
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National Patient Safety Foundation
Ask Me 3—Program Materials (Available in English and Spanish)
Organizational BrochureWebsite
Provider Brochure
Posters
Patient Brochure
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Communication Enhancement Tools
http://www ahrq gov/questions/pcvideos htmhttp://www.ahrq.gov/questions/pcvideos.htm 13 free videos Patients, doctors, and nurses talk about how simple , , p
questions can help make a big difference
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Requirements
FAC 64B8-13.005(c) (MD)FAC 64B15 13 001(3)(f) (DO)*FAC 64B15-13.001(3)(f) (DO)*
• Cancer• Cardiac conditions*• Cardiac conditions• Neurological conditions• Acute abdomen related conditionsAcute abdomen related conditions• Timely diagnosis of surgical complications• Diagnosis of pregnancy related conditionsg p g y• Inappropriate opioid prescribing*• Wrong-site surgery
13Prevention of Medical Errors / 13
Error Prevention - FTD/DID Cancer
Breast cancer Lung cancer Cervical cancer Colon cancer
Claims involving breast cancer are among the most prevalent and expensiveamong the most prevalent and expensive
type of malpractice claims
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Error Prevention—FTD/DID Cancer
A high index of suspicion is warranted when t titreating younger women
Age group 40-49 continues to account for the g g pmost paid claims, accounting for 30.8 percentof total paid claims, and 34.2 percent of the total indemnity paidtotal indemnity paid
Average age 43.6 years
PIAA Breast Cancer Study
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PIAA Breast Cancer Study
FTD/DID Surgical Complications
Most claims entail acceptable medical complicationsp
Failure to supervise/monitor post-op is the most prevalent root cause of medical error
Prevalent post-op complications: Infection Perforation Suture failure
Bl di Bleeding
Foreign body retention–res ipsa loquitur case
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Wrong-Site/Wrong Procedure Surgery
58% ambulatory settings 29% in-patient OR p13% other in-patient settings–ER, ICU
76% wrong body part or site 13% wrong patient11% wrong surgical procedure11% wrong surgical procedure
Communication is the most prevalent RC in 78% of casescases
Orientation and training in 45% of cases
Joint Commission on Accreditation of Healthcare Organizations
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Joint Commission on Accreditation of Healthcare Organizations
Preventing Wrong-Site/Wrong Procedure Surgery
FAC 64B8-9.007 (MD) and 64B15-14.006 (DO)
Standards of Practice
(2) “ requiring the team to pause prior to initiation(2) …requiring the team to pause prior to initiation of the surgery/procedure to confirm the side, site, patient identity, and surgery/procedure.”
(b) “…the notes of the procedure shall specifically reflect when this confirmation procedure was completed and
hich personnel on the s rgical team confirmed eachwhich personnel on the surgical team confirmed each item.”
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FTD/DID Acute Myocardial Infarction
Diagnostic Errors
Pain/pressure (primarily chest) cited in 93% of cases GI diagnosis was the most common clinical impression.GI diagnosis was the most common clinical impression. EKG was ordered in 59% of cases
(diagnosis missed in >50% of those cases) <31% attributed a cardiac origin 77% - died as a result of diagnosis and treatment errors
f C S
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PIAA Myocardial Infarction Claim Study
Error Prevention - AMI
Maintain same index of suspicion for office patients as those in the ER or CCUpatients as those in the ER or CCU
Document all complaints of pain/pressure d it l tiand its location
Document recommendations for subsequent diagnostic studies and treatment
Promptly report positive diagnostic findings p y p p g gto referring physician
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Inappropriate Opioid Prescribing
Pain management claims are among the most diffi lt t d f ddifficult to defend
Nearly one-half result in indemnity payment Undiagnosed psychiatric conditions, addition
and/or diversion are frequent factors FS 456.44(c) Controlled substance prescribers
specifically detailed
PIAA Research Notes
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PIAA Research Notes
Failures in Opioid Prescribing
Failure to evaluate (inadequate history, PE) FTD prior to initiation of treatment FTD prior to initiation of treatment
(inadequate medical rationale) Failure to obtain medical records or verification Failure to obtain medical records or verification
(no documentation) Failure to establish treatment goalsFailure to establish treatment goals
(pain reduction–improvement) FTD abuse (no screening/monitoring ofFTD abuse (no screening/monitoring of
addictive potential)
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Failures in Opioid Prescribing (continued)
Deviation from the “Contract” (no documentation)(no documentation)
Blind acceptance
System failure (drug testing results)
Faulty rationale (unsupported clinical correlation)
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FTD/DID/MSD: Acute Abdomen
• Appendicitis• Esophageal varices
• GERD• Renal stones• Esophageal varices
• Abdominal aortic aneurysm
• Renal stones• Hiatal hernia• PIDy
• Colitis• Hernia of abdominal wall
• Peptic ulcer disease• Pancreatitis
IBS• Cholecystitis/lithiasis• Ectopic Pregnancy
Di ti l i
• IBS• Gastroenteritis
• Diverticulosis
Encountered in 5-10% of all ER visits
24PIAA Data Sharing System Report 1985-2007
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Missed Diagnosis:Pregnancy and Its Complications
• Failure to diagnose • Ectopic Pregnancy• Gestational Diabetes
P E l i /E l i• Pre-Eclampsia/Eclampsia• Failure to diagnose pregnancy prior to
treatmenttreatment• Procedure• Medications• Medications
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Case Summary
• 18-year-old femaleH d h f t• Headaches for two years
• Six trips to Urgent Care• Six different doctors, one chiropractor• Dx: Sinusitis, stress • Tx: Antihistamines, antibiotics, pain meds
FTD/WD
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Missed Diagnosis: Neurologic Condition
Failure in diagnostic testing to:
Don’t be fooled by youth Explore history of trauma Adequately evaluate and document clinical signs Perform brain imaging
Obt i l i lt ti Obtain neurologic consultation
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Root Cause Analysis
Structured and process-focused framework Credible and thorough Active and latent–what, how, and why Specific underlying causes Reasonably identifiable
C t ll d i fl d Controlled or influenced
Generate specific recommendations
Primary aim: Avoid culture of individual blame
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MEDICAL ERROR
1. Type of Error 2. 3.
Risk Points
Processes Systems
Causal Factors___________
___________ ___________
___________ ___________ ___________
Clinical Organizational___________ ___________
CorrectiveMeasures
Corrective Measures
2
1.________
2
1. _______ Implementation
1. _______ Measurement of Effectiveness
293. _______
2.________
3. _______
2. _______2. _______
3. _______
Disclosing Medical Error
Duty to notify patients - FS 456.0575 Seek legal/risk management guidance Communicate Express concern/empathy Do not blame Present a plan Confirm understanding Document
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Primum Non Nocere
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Mission Statement
cliffrapp@thedoctors.com(800) 741-3742, ext. 3016
Our Mission Is to AdvanceOur Mission Is to Advance, Protect, and Reward the
Practice of Good MedicinePractice of Good Medicine
For further Patient Safety informationFor further Patient Safety information,please visit our Web site at:
www.thedoctors.com
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