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 Physicians and European Federation of Internal Medicine in 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 STUDENTSFACULTY Interprofessional TeamsInformation 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

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