A Patient Safety Conference 60 Minute RCA A Patient Safety Conference Matthew Ronan, MD @mvronan Lakshmana Swamy, MD @laxswamy

Objectives Case through Timeline (2) Introduce and Use a Fishbone diagram Hierarchy of interventions Impact/Effort Matrix Key Concepts and skills

Fishbone Diagram Great! So-so Not so much Level of comfort with each of the following?

Hierarchy of interventions Great! So-so Not so much

Impact/Effort Matrix Great! So-so Not so much

Definitions Adverse Event (AE): harm from medical care rather than an underlying disease.  Error: any act of commission or omission that exposes patients to a potentially hazardous situation. Near Miss: an unsafe situation indistinguishable from a preventable AE except for the outcome. A patient is exposed to a hazardous situation, but does not experience harm either through luck or early detection.

Case 1 69 year old male veteran with PMH of CAD s/p CABG presents to the Emergency Department with chest pain. Unstable angina Heparin drip Admitted to cardiology

Emergency Department Course 15:00 15:15 17:15 PTT: 31.9 seconds Aspirin 325 mg Heparin bolus 4000 units Heparin gtt 1000 units/hr Medications administered in emergency department do not appear in eMAR 4000 units

Hospital Course 14000 units 4000 units 6000 units 7000 units 17:53 19:08 20:22 23:17 Holding orders placed, including initial heparin bolus Patient arrives to floor on heparin infusion Heparin bolus 4000 units PTT 179 seconds 19:58 ED nursing note signed Holding orders placed, including another initial heparin bolus Arrives to the inpatient ward already on a heparin infusion at 1000 units/hr. By this point he has received 6000 units heparin Subsequently the ED nursing note is signed and visible to other providers Based on his weight, he receives another 4000 unit bolus -> 11000 units total 3 hours later 1st PTT results. Therapeutic range is 50-70 seconds for ACS His heparin infusion is appropriately held and no patient harm is noted 4000 units 14000 units 6000 units 7000 units 11000 units

Case 2 80 year old male with PMH: CAD s/p CABG, HFrEF 2/2 iCMY, Severe AS, new diagnosis of afib on warfarin Admitted to cardiology for staged PCI Warfarin held on admission, with plan for heparin bridge after 1st PCI

Returns to inpatient ward Hospital Course 13:20 13:47 11:00 – 13:20 Heparin 8000 units in cath lab Returns to inpatient ward Written for heparin gtt, including initial bolus Unclear how/when in cath lab he received heparin Also not entirely clear if he leaves the cath lab on a heparin drip. For our purposes I’ll assume not Regardless he is written for a heparin drip on return to the floor, including initial bolus Pt weighs 84 kg 8000 units

Hospital Course 20300 units 8000 units 14500 units 16:14 16:14 20:30 Heparin bolus 6500 units Heparin gtt 1450 units/hr PTT > 200 Based on his weight, he receives 6500 unit bolus -> 14500 units total Placed on an infusion Therapeutic range for PTT is 59-107 seconds for PE/DVT 20300 units 8000 units 14500 units

Hospital Course Continued No evidence of hematoma, normal distal pulses Hemoglobin 12.2 -> 11.3 -> 10.7

What factors contributed to these events? People Environment Communication Policy/ procedure People - Environment Communication – nocturnist not notified about low BP Policy/procedure Training/experience – new RN Information systems - Training/ experience Information systems

What factors contributed to these events? People

What factors contributed to these events? Environment

What factors contributed to these events? Communication

What factors contributed to these events? Policy/procedure

What factors contributed to these events? Training/Experience

What factors contributed to these events? Information Systems

What factors contributed to these events? People Environment Communication Busy teams Handoffs - MD-MD, RN-RN Pharmacists Change of shift Pharmacy support Pharm-Pharm Fatigue ED/inpatient physicians and nurses geography Silos Heparin policy EMR training No unified med admin Who can order it Learning protocol Delays Hard to find the order Local factors, i.e. cath No EMR Support for orders Policy/ procedure People - Environment Communication – nocturnist not notified about low BP Policy/procedure Training/experience – new RN Information systems - Training/ experience Information systems

How can we prevent this?

Hierarchy of actions Stronger Weaker streamline/simplify process standardize process engineering controls (forcing functions) architectural changes redundancy checklists enhanced documentation Weaker double checks training new policy Substitution test

Ideas for improvement

Ideas for improvement YES! I want this done yesterday. I’m listening… we’ll consider it. LOW HIGH Impact Sure. Why not? Don’t even think about it. LOW Effort HIGH

Ideas for improvement LOW HIGH Impact LOW Effort HIGH

Ideas for improvement Change RN signout to electronic record Fix order set to have an optional bolus Dedicated anticoagulation pharmacist for all anticoagulation LOW HIGH Impact Give patient a med rec post-it note Create a screen saver Create a policy Change EHR Have scribes/volunteers Create a training Move to a paper MAR in the ED LOW Effort HIGH

Take Home Points Use patient safety cases and front-line staff to identify and improve patient safety issues Understand and apply QI tools in a rapid RCA format Develop improvement interventions using the hierarchy of intervention and impact/effort matrix to prioritize initiatives