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double-sickening • Pharyngitis: Abx only if rapid strep test • Bronchitis: Abx are not necessary • If bacterial suspected, get cultures • Use respiratory PCR to de-escalate Chow AW. Clin Infect Dis. 2012;54:e72 Shulman ST. Clin Infect Dis 2012’ 55: e86-102 Gonzalez. Ann Int Med 2001; 134: 521-9 Break Transmission: Hand Hygiene Break Transmission: Adhere to Appropriate Precautions • Standard precautions • Transmission-based • Contact: direct / indirect • Droplet (large, >5 µm) • Airborne (small, <5 µm) • Endogenous or devices Reexamine Role of PPE JAMA Int Med Oct 12, 2015 How Common is Presenteeism among Healthcare Professionals? Jena AB. Arch Intern Med 2012; 172: 1107-08 • 51% reported working with flulike symptoms at least once in the past year, 16% at least 3 times • 30% admitted they or another ill colleague transmitted their illness to a patient 5. Missed Pulmonary Embolism • Headline: Woman, 21, killed by Pill after nurse missed blood clot • CC: chronic chest pain and breathlessness, on contraceptives • Given ibuprofen and told to rest http://www.express.co.uk/news/uk/636231/Woman-killed-Pill-nurse-missed-blood-clot Pulmonary Embolism & DVT • Commonly misdiagnosed • About 1/3 had delayed or misdiagnosis of PE • Among patients with DVT, 1/3 had asymptomatic PE • Risk factors: prior thrombosis, recent major surgery, hospital admission, CVC, trauma, immobilization, malignancy, pregnancy, OCPs, tobacco • Common sx: dyspnea (73), pleuritic pain (66), cough (37) • Common signs: tachypnea (54), calf /thigh swelling (47), tachycardia (24), rales (18) • Lab tests are non-specific • CXR may be normal, but can also show atelectasis, parenchymal abnormalities, pleural effusion, and cardiomegaly Torres-Macho. Am J Emerg Med, 2013: DOI http://dx.doi.org/10.1016/j.ajem.2013.08.037 Approach to Diagnosing PE • Assess pretest probability – Wells Criteria (points) • Symptoms of DVT (3) • No alternative diagnosis to better explain illness (3) • Tachycardia >100 (1.5) • Immobilization ≥ 3d (1.5) • Prior history of DVT or PE (1.5) • Hemoptysis (1) • Malignancy (1) • D-dimer assay: sensitive, helpful for low or moderate probability • CT pulmonary aniogram, V/Q scan, lower extremity ultrasound • Treatment: anticoagulation Score >6: High probability Score >=2 and <=6: Moderate probability Score <_x0032_: Low Probability Error Prevention for Common Misdiagnosed Conditions _x2022_ Investigate _x2022_ Complaints related to these conditions _x2022_ Risk factors related to those conditions _x2022_ Consider atypical symptoms and age considerations _x2022_ Document _x2022_ H_x0026_P_x002c_ phys exam_x002c_ pertinent negatives _x2022_ Rationale for giving or withholding treatment _x2022_ Review follow up _x2022_ All lab studies and compare with previous _x2022_ Avoid reliance on single test result_x002c_ esp if negative or equivocal _x2022_ Delinquent follow ups: establish system in writing _x2022_ Communicate _x2022_ Consider referral _x2022_ Educate patients re: risk factors How Documentation Helps _x2022_ It provides proof you did the right thing _x2022_ Supports idea you gave adequate thought and consideration to the case _x2022_ Tips _x2022_ Document your advice _x2022_ Document thought process and differential _x2022_ Legibility _x2022_ NEVER_x002c_ NEVER_x002c_ alter after the fact _x2022_ Don_x2019_t editorialize Source: J. Davenport_x002c_ MD JD accessed at http: _x002f_www.aafp.org _x002f_fpm _x002f_20001000 _x002f_33docu.html Concepts to Improve Patient Safety Communicating and follow up Manage burnout Case Presentation: No News May Not Be Good News _x2022_ A _x0032_4 year-old male with no previous medical history was admitted for _x0033_ days of fever up to _x0031_03_x002c_ headache _x0039_ _x002f_10_x002c_ eye pain_x002c_ photophobia and mild sore throat _x2022_ PMH: GERD and Crohn_x2019_s disease _x2022_ Medications: omeprazole_x002c_ Vicodin PRN _x2022_ SH: No tobacco or drug use_x003b_ social EtOH_x003b_ no information about sexual history or orientation is obtained _x2022_ PE: T _x0031_02.1_x002c_ HR _x0038_0_x002c_ RR _x0031_8_x002c_ BP _x0031_28 _x002f_76_x002c_ O2 _x0031_00_x0025_ RA _x2022_ No acute distress_x002c_ no meningismus_x002c_ no rash _x2022_ Labs: CBC_x002c_ CMP WNL CP_x002c_ continued _x2022_ The resident diagnoses patient with a viral syndrome_x003b_ started on ceftriaxone and vancomycin _x2022_ Blood cultures drawn _x2013_ eventually negative _x2022_ Meningitis is ruled out with a lumbar puncture_x002c_ which is negative _x2022_ Monospot_x002c_ beta strep group A are ordered and negative _x2022_ An HIV PCR quantitative test is ordered _x2022_ The next day_x002c_ patient is feeling better_x002c_ _x0038_ _x002f_10. On hospital day _x0033__x002c_ patient is discharged_x002c_ with instructions to follow up with PCP and attending agrees CP_x002c_ continued _x2022_ Patient follows up with PCP_x2026_8 months after discharge. _x2022_ He has _x0037_ additional visits in his PCP office for URIs_x002c_ physical exams _x2022_ _x0032_ years after discharge_x002c_ he spends time at Disney Gay Days_x002c_ gets screened for HIV by DOH via rapid test_x002c_ which is positive _x2022_ PCP looks back in the electronic medical record and finds that HIV Quant VL is/>10,000,000 Background: Laboratory Testing • Adage: “If you ordered it, you own it” • Failure to follow up radiographic and laboratory testing is a significant cause of medical errors • Fastest growing area of malpractice litigation involves failures or delays in diagnosis • Up to 25% of these lawsuits are from avoidable failures in the test follow-up system Laboratory Testing in the Ambulatory Setting • Almost one quarter of all medical errors in ambulatory settings are due to inadequate follow-up of abnormal test results • In one study, 15% of abnormal tests suggestive of diabetes were never followed up by clinicians; about 9% of these patients had unrecognized (and untreated) diabetes • In another, primary care practice over a 4-year period, the median time for follow-up for marked hyperkalemia was 3 days. In 14% of these cases, no follow-up occurred until patients returned for routine follow-up or they visited the practice for other reasons Reasons for Missed Test Results • Hospitalists and ED: “out of sight, out of mind” • Not because we don’t lack effort: physicians report spending more than 70 minutes per day on test result management, reviewing more than 1000 results per week on average • Largely a system problem: automated systems can help, but not every issue has an automated system solution Root Cause Analysis • Process to identify underlying (basic or causal) causes of medical error • Focus on systems / processes, not individual • Seeks to answer • What happened? What should have happened? • Why did it happen? • How can we prevent from happening again? • How do we know that our actions improved patient safety? RCA Analysis Steps Overview 1. Get interdisciplinary team 2. Reconstruct sequence of events • Review available data / documents / resources • Generate questions, perform site visits, interviews • Flow diagram: what happened? • Construct ideal sequence of events 3. Identify and categorize root causes and contributing factors Objectives Upon completion of this course, the learner will be able to: · Discuss the extent of the problem of medical errors in healthcare. · Discuss the definition of medical errors. · Identify patient safety organizations working on the issue of medical errors. · Describe 10 priority evidence-based patient safety interventions promoted by the Agency for Healthcare Research and Quality. · Discuss the development of a Healthcare Partnership between professionals and patients. · Identify principles from the National Patient Safety Foundation’s Universal Patient Compact. Introduction The safety of the patients in our care and treatment is an important goal during all healthcare encounters. Early studies in the 1960s already pointed to healthcare related errors as a problem for healthcare consumers. However, it was the startling report in 1999, from the Institute of Medicine (IOM) To Err is Human, that served as a wake-up call for healthcare professionals, multiple public and private healthcare and healthcare-related organizations, state legislatures and the federal government. The IOM report estimated that between 44,000 and 98,000 deaths annually are a result of medical errors; more than half of the adverse medical events occurring each year are due to preventable medical errors, causing