1. Medical Service Professional’s Role in Improving Patient Safety and Decreasing Organizational Legal Risk November 13, 2015

2. A patient story…
2 month old Patient underwent surgery to repair closure of ventriculoseptal defect and atrial septal defect. Surgeon inadvertently sutured valve shut. Prognosis is terminal. Initially when report the root cause analysis was conducted and the physician wanted it to remain a peer review issue only due to surgical technique. It was a human error. However, after some discussion and persuasion, the physician agreed to review the case with the team that was in the operating room at the time. Of course, this was a very complex case in a very small body. However, there was a point after the cross clamp was removed from the aorta that the infant failed to have any urinary output. This continued throughout the closure of the procedure, lasting about 45 minutes. While unusual, no one mentioned that there was ZERO “0“ output. This was a signal to the physician that something was wrong with perfusion. This would have prompted a re-look at the closure cavity.
Physicians do not work in a vacuum, even though culturally and socially we treat them like they do.

3. Decreasing Legal Risk Primary source verification
Completed appointment forms
Sharing previous case history with legal or credentialing committee

4. Decreasing Legal Risk Normal course of business
Hammond v. Saini – NC Supreme Court decision
Protecting your documents

5. Decreasing Legal Risk
Peer Review
Confidentiality
Protection
Safety

6. Decreasing Legal Risk Patient Safety
Participating in Root Cause Analysis
Encouraging frank safety discussion
Risk reduction
Regulatory issues
Medical Staff bylaws
Rules & Regulation
Policies

7. Decreasing Risk Physicians are part of the TEAM! Leadership Ownership
They are not the expert in everything

8. Improving Patient Safety
Just Culture
Punitive environment
Transparency
Secrecy
Patient Centered
Provider Centered
Interdependent collaborative,
interprofessional teamwork
Reliance on independent, individual performance excellence
System failures
Errors as individual failures

9. Improving Patient Safety
Just Culture
Punitive environment
Transparency
Secrecy
Patient Centered
Provider Centered
Interdependent collaborative,
interprofessional teamwork
Reliance on independent, individual performance excellence
System failures
Errors as individual failures

10. Improving Patient Safety
Simulation practice insertions
Insertions with supervision
Standardize insertion kits
Barrier on proximal end to hold it
Errors as individual failures
System failures

11. Improving Patient Safety
Punitive environment
Skill based error – honest mistake
Just Culture

12. Skill based error – honest mistake
Punitive environment
Just Culture

13. Improving Patient Safety
Secrecy
Share the story, peers learn from honest mistakes made from others
Transparency

14. Improving Patient Safety
Provider Centered
Patient had IO access and fistula
Culture is to place CVC during Code Blue
Patient Centered

15. Improving Patient Safety
Designate a CVC buddy to assist with procedure and/or to determine that all equipment, including guidewire, is retrieved appropriately following procedure
Reliance on independent, individual performance excellence
Interdependent collaborative,
interprofessional teamwork

16. Medical Service Professional’s Role in Improving Patient Safety and Decreasing Organizational Legal Risk November 13, 2015