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

2. COPYRIGHT 2013 VIDANT HEALTH A patient story… 2

3. COPYRIGHT 2013 VIDANT HEALTH Decreasing Legal Risk Primary source verification Completed appointment forms Sharing previous case history with legal or credentialing committee 3

4. COPYRIGHT 2013 VIDANT HEALTH Decreasing Legal Risk Normal course of business Hammond v. Saini – NC Supreme Court decision Protecting your documents 4

5. COPYRIGHT 2013 VIDANT HEALTH Decreasing Legal Risk Peer Review Confidentiality Protection Safety 5

6. COPYRIGHT 2013 VIDANT HEALTH Decreasing Legal Risk Patient Safety Participating in Root Cause Analysis Encouraging frank safety discussion Risk reduction –Regulatory issues –Medical Staff bylaws –Rules & Regulation –Policies 6

7. COPYRIGHT 2013 VIDANT HEALTH Decreasing Risk Physicians are part of the TEAM! Leadership Ownership They are not the expert in everything 7

8. COPYRIGHT 2013 VIDANT HEALTH 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. COPYRIGHT 2013 VIDANT HEALTH 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. COPYRIGHT 2013 VIDANT HEALTH Improving Patient Safety Simulation practice insertions Insertions with supervision Standardize insertion kits Barrier on proximal end to hold it 10 System failures Errors as individual failures

11. COPYRIGHT 2013 VIDANT HEALTH Improving Patient Safety Skill based error – honest mistake 11 Just Culture Punitive environment

12. COPYRIGHT 2013 VIDANT HEALTH Skill based error – honest mistake 12 Just Culture Punitive environment

13. COPYRIGHT 2013 VIDANT HEALTH Improving Patient Safety Share the story, peers learn from honest mistakes made from others 13 Transparency Secrecy

14. COPYRIGHT 2013 VIDANT HEALTH Improving Patient Safety Patient had IO access and fistula Culture is to place CVC during Code Blue 14 Patient Centered Provider Centered

15. COPYRIGHT 2013 VIDANT HEALTH 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 15 Interdependent collaborative, interprofessional teamwork Reliance on independent, individual performance excellence

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