Patient Safety Conference
The Patient Safety Conference is an interactive session designed to guide the group through a modified root cause analysis/systems analysis. Each R3 will lead 1 PSC during the year.
During your in-patient team leading month, recent office sessions, or OB rotation, think about the various cases you come across that result in an adverse patient event or have the potential for patient harm (see below for some ideas of adverse patient events)
Goals include:
Make the most of a learning opportunity in order to improve quality and patient safety. The goal is NEVER to blame, judge or belittle.
Practice coping skills for emotional distressing topics and events
Promoting an attitude of continual self improvement
Participate in a modified root cause analysis process
Ground rules for the conference include:
Adverse patient events often cause emotional responses such as distress, guilt, self-doubt, frustration and anger. This is a NONJUDGMENTAL environment to share those emotions and openly discuss patient mishaps
Details of the patient case and subsequent discussion are confidential. Med students who are AI's are invited, other students are not. It is expected that details of the case will not be discussed outside the setting of the conference.
Links for the full details of expectations are here and below.
To prepare, complete a MIDAS report if not already done (TCH's error reporting system) and the Root Cause Analysis Worksheet. Additional preparation resources are below.
Ask 1-2 of our interprofessional colleagues to join us for PSC! They bring great insight and can share the differences in their workflow compared to ours. This could be an RN, Social work, care manager or coordinator, pharmacist or anyone else. Use your case to determine the best invitees (e.g. discussion on a medication error might be helped by inviting a pharmacist).
Be sure to ask Dr Rich about getting protected time in the week following the conference for follow up on solutions (1 hr)
Questions or concerns? Email Dr Rich
Key Concepts:
Definitions: what is a medical error? What is an adverse patient event? Are they the same? Brush up on your vocabulary here.
How do you disclose an error to the pt and/or family? From the MA Coalition for the Prevention of Medical Errors (2006): Brief version, extended version, additional resources.
Self care after an adverse patient event: What do you do to cope and to heal? Read one resident's story and peruse the coping mechanisms utilized by these medical students. Additional resources are on the Wellness page.
Timeline Summary: Begins with the last day of the TL month
Weeks 1& 2: select case and do online Root Cause Analysis Worksheet
Week 3: do lit search (write down your sources - 1 to 3 sources is sufficient) and meet with faculty member (either attending for the case or Drs Rich or Mount)
Weeks 4 & 5: prepare case presentation (powerpoint is rarely necessary), lead group discussion.
Week 6: Turn in write up to Dr Rich or Dr Mount. Be sure to include list of sources from your literature search.
Categories of medical errors and/or adverse patient events
Avoidable admission (e.g. suboptimal pain control)
Prolonged length of stay (e.g. delayed study, complications from procedures, difficulty with SNF placement)
Medication error or reaction (e.g. wrong med/dose administered either due to physician or nursing error, allergic reactions to abx, angioedema from ACE/ARB, AKI from diuretic, elevated INR resulting in bleeding)
Death (whether expected or not)
Procedure complication (e.g. contrast induced nephropathy)
Outpt complication (e.g. PCP starts pt on NSAIDs and then they are adm for GIB or AKI; in general i think this is best served if the PCP is one of us)
ICU transfer (whether avoidable or not)
Other (fired by pt/family or something else that doesn't fit into one of the above categories)
Conference Format
2 min: Review of goals and ground rules, as described above
2-3 min: case presentation by team leader
10 min: Large group brainstorming and case/systems analysis (why did it happen? what are contributing causes? Think in large categories (e.g. communication error))
10 min: Break into small groups for brainstorming solutions (what can we change to prevent this from happening the future?)
10 min: Small groups report their solutions
5 min: TL presents findings from lit search and leads wrap up including suggestions for next actionable steps (although assigning responsibility for f/u may not be done at every conference, as we will not be able to perform a QI project for every conference)
TL evaluation form - completed by faculty and chief residents present at the conference
Resources
Institute for healthcare improvement website and AHRQ Web M&M may be good starting points for literature search
leading a group discussion tips
"Fishbone" technique
1.Medical Knowledge and Patient Care:
Resident correctly identifies adverse patient events during his/her adult
in-patient medicine rotation.
Resident correctly categorizes all possible causes of adverse event
Resident applies knowledge and experience from adverse patient event(s)
to identify need for change in personal practice
2.Problem Based Learning
Resident exhibits an investigatory approach to areas of adverse patient
events: generates questions, applies information to the clinical situation, responds to feedback, identifies areas of potential improvement and disseminates information to colleagues.
Resident participates in a modified root cause analysis/systems analysis including critically reviewing an adverse event and recommending a plan of action
Resident performs a brief literature search for determining prevalence and possible solutions to a type of adverse patient event
Resident completes an online self-reflection of clinical encounter(s) and identifies learning opportunity from an adverse patient event
Resident models an attitude of life-long learning and identifies strategies for continued personal growth as a physician
3.Interpersonal and Communication Skills
Resident reviews the patient case with members of the team including
junior residents and supervising faculty prior to presentation
Resident facilitates a group discussion on the case(s) selected in a setting
of his/her peers
Resident communicates succinctly the facts of the case with the group
Resident maturely and appropriately discusses sensitive topics around
patient care
Resident models fostering an safe and inquisitive environment for group
discussion
4. Professionalism
Resident exhibits the following character traits: respectful of others,
honesty, hard-working, responsible, receptive to feedback, compassionate
toward others, altruistic
Resident maintains poise/emotional control, even during difficult topics or
in stressful situations
c. Resident identifies his/her limitations as a physician and shows a willingness to examine and learn from adverse patient events
d. Residents utilizes and models appropriate coping skills after an adverse patient event, including talking with peers and mentors, learning from mishap, taking actionable steps, and accepting responsibility/ acknowledging a mistake.
5.System Based Practice
Resident demonstrates patient advocacy including advocating for systems
change after an adverse patient event
Resident identifies system errors and gaps in quality and patient safety
Resident generates possible actionable steps for improvement of patient
safety and quality of care, either in an out-patient or in-patient setting
Schedule
