Chat with us, powered by LiveChat How common are these errors reviewed on the previous slides 1-47 in this week’s lecture presentation? What are the top sentinel events in the hospital setting - Tutorie

How common are these errors reviewed on the previous slides 1-47 in this week’s lecture presentation? What are the top sentinel events in the hospital setting

1. How common are these errors reviewed on the previous slides 1-47 in this week's lecture presentation? What are the top sentinel events in the hospital setting?  Research Joint Commission (joint commission.org)and Institute for Healthcare Improvement (IHI.org)

2. What are some factors contributing to these errors?

3. What outcomes do they lead to (ex: what types of adverse events, mortality rate, cost, etc.)?

4. How should this problem be addressed (ex: best practices)? 

Medical Staff Liability

Medical Staff Organization

Committees

Executive Committee

Bylaws Committee

Blood and Transfusion Committee

Credentials Committee

Infection Control Committee

Medical Records Committee

Pharmacy and Therapeutics Committee

Quality Improvement Council

Tissue Committee

Utilization Review Committee

Executive Committee

Recommends medical staff structure

Develops a process for reviewing credentials

Recommends appointments to the medical staff

Develops processes for delineating clinical privileges

Executive Committee

Performance improvement activities

Peer review

Fair hearing process

Reviews and acts on reports of medical staff departmental chairpersons and medical staff committees

Bylaws

Organization of the medical staff is described in its bylaws, rules, and regulations

Bylaws must be approved by the governing body

Bylaws must be kept current and the governing body must approve recommended changes

Bylaws describe various membership categories of the medical staff (e.g., active, courtesy, consultative)

Blood and Transfusion

Develops blood usage policies and procedures

Monitors transfusion services

Monitors

Indications for transfusions

Blood ordering practices

Each transfusion episode

Transfusion reactions

Credentials

Oversees application process for medical staff applicants, requests for clinical privileges, and reappointments to the medical staff

Makes its recommendations to the medical executive committee

Infection Control

Generally responsible for the development of policies and procedures for investigating, controlling, and preventing infections

Medical Records

Develops policies and procedures, including:

Release, security, and storage

Determining the format of medical records

Monitoring records for accuracy

Completeness, legibility, and timely completion, and clinical pertinence

Ensures records reflect condition and progress of the patient, including results of all tests and therapy given and makes recommendations for disciplinary action as necessary

Pharmacy and Therapeutics

Policies and procedures (e.g., selection; procurement; distribution; handling, use, and safe administration of drugs, biologicals, and diagnostic testing material)

Oversees development and maintenance of formulary

Evaluates and approves protocols for the use of investigational or experimental drugs

Pharmacy and Therapeutics

Oversees:

Tracking of medication errors

Adverse drug reactions

Management, control, and effective and safe use of medications through monitoring and evaluation

Monitoring of problem-prone, high-risk, and high-volume medications

Quality Improvement Council

Functions as a patient-care assessment and improvement committee

Tissue

Provides surgical case reviews, including:

Justification and indications for surgical procedures

Utilization Review

Monitors and evaluates utilization issues such as medical necessity and appropriateness of admission and continued stay, as well as delay in the provision of diagnostic, therapeutic, and supportive services

Ensures each patient is treated at the appropriate level of care

Utilization Review

Objectives of the committee include

Transfer of patients requiring alternate levels of care

Promotion of efficient and effective use of resources

Adherence to quality utilization standards of third-party payers

Maintenance of high-quality, cost-effective care

Identification of opportunities for improvement

Medical Director

Serves as a liaison between medical staff and organization’s governing body and management

Responsibilities include enforcing the bylaws of the governing body and medical staff and monitoring the quality of medical care in the organization

Medical Staff

Credentialing: Screening and evaluating qualifications

Appointment: becoming a member of the medical staff

Privileges: identifying the specific procedures and patient care services a physician will be able to provide at certain sites

Medical Staff Privileges

Screening process

Application

Medical staff bylaws

Physical and mental status

Consent for release of information

Certificate of insurance

State licensure

National practitioner data bank

References

Interview process

Medical Staff Privileges

Delineation of clinical privileges

Limitations on privileges requested

Practicing outside field of competency

Governing body responsibility

Misrepresentation of credentials

Appeal process

Must exhaust all remedies provided in a hospital’s bylaws before seeking legal action

Reappointments

Should be reviewed every 2 years

Common Medical Errors

Patient assessment

Diagnosis

Treatment

Discharge

Follow-up care

Patient Assessments

Involve the systematic collection and analysis of patient-specific data necessary to determine a patient’s care and treatment plan

A patient’s plan of care is dependent on the quality of assessments conducted by practitioners of various disciplines (e.g., physicians, nurses, dietitians)

Patient Assessments Examples

Unsatisfactory History and Physical Exam

Assessment of Unconscious Patient

Any physician should reasonably anticipate head injuries when car strikes a person

Failure to Obtain a Second Opinion when Requested

Assessments Sometimes Require Referral to a Specialist

Aggravation of Patient’s Condition

Liability only imposed for aggravation

Diagnosis

Refers to the process of identifying a possible disease or disease process, thus providing the physician with treatment options

A wrong diagnosis will not in and of itself support a claim of negligence

Patient must be examined adequately (physician must use ordinary care)

Diagnosis

Failure to order diagnostic tests

Plaintiff needs to show:

It is standard practice to use a certain diagnostic test under the circumstances of the case

The physician failed to use the test and therefore failed to diagnose the patient’s illness

The patient suffered injury as a result

Diagnosis Examples

Efficacy of test questioned

Is failure to order test a substantial factor in causing patient’s injury or death?

Failure to promptly review test results

Timely diagnosis (reducing chance of survival)

Failure to Read X-Ray Report

Failure to Monitor Patient

Diagnosis – Imaging Studies

Imaging studies

Failure to Order Appropriate Imaging Studies

Image Misinterpretation Leads to Death

Failure to Consult with Radiologist

Failure to Read Images

Delay in Conveying Imaging Results

Failure to Communicate Imaging Results

Diagnosis

Most frequently cited injury event in malpractice suits against physicians

Medicine is not an exact science and linking a patient’s symptoms to a specific ailment is complicated at best

Sometimes things go wrong despite all the advances of modern medicine

Diagnoses based on false test results

Can lead to harmful treatments

Accident Victim: Misdiagnosis

The police department physician examined an unconscious man who had been struck by an automobile.

The physician concluded the patient’s confusion was due to intoxication and he was placed in jail instead of a hospital.

The man remained semiconscious for several days and was finally taken to a hospital at the insistence of family; he subsequently died.

The autopsy revealed massive skull fractures.

Did the physician commit malpractice?

Accident Victim: Misdiagnosis

Yes!

A patient is entitled to a thorough examination as his or her condition and attending circumstances warrant.

This did not happen

Treatment

The attempt to restore the patient to health following a diagnosis

Involves the application of various remedies and medical techniques, including surgery and medications

Forms of Treatment

Active treatment is directed immediately to the cure of the disease or injury

Causal treatment is directed against the cause of a disease

Conservative treatment is designed to avoid radical medical therapeutic measures

Palliative treatment is designed to relieve pain and distress with no attempt to cure

Forms of Treatment

Preventive/prophylactic treatment is aimed at the prevention of disease and illness

Supportive treatment is directed mainly to sustaining the strength of the patient

Symptomatic treatment is meant to relieve symptoms without effecting a cure

Treatment: Choice of Treatment

Two schools of thought doctrine:

Applicable in medical malpractice cases in which there is more than one method of accepted treatment.

Under this doctrine, a physician will not be liable for medical malpractice if he or she follows a course of treatment supported by reputable, respected, and reasonable medical experts.

Use of unprecedented procedures that create an untoward result may cause a physician to be found negligent.

Treatment Examples

Selecting the wrong treatment

Failure of attending physician to recognize recommendations of consulting physicians

Delay in treatment

Failure to treat known condition

Failure to treat evolving emergency

Failure to respond to emergency calls

Treatment: Medication Errors

Limited and judicial use

Documentation of use and continuation

Medication errors

Wrong Dosage

Negligent drug overdose

Abuse in Prescribing Medications

Wrongful Supply of Medications

Medication Errors

Medication errors

Failure to administer drugs

Failure to document drug wastage

Administering drugs without a prescription

Administering wrong medication

Failure to clarify orders

Medication Errors

Administering by the wrong route

Failure to discontinue medication

Failure to identify correct patient

Failure to note order change

Treatment: Surgery

Surgery

Wrong Patient Surgery

Correct Surgery: Wrong Site

Foreign Objects Left in Patients

Procedure Improper

Endotracheal tube removed too soon after surgery

Improper Positioning of Arm

Preventing Surgical Mishaps

Require second opinions

Qualified credentialed physician for proposed procedure

Patient informed as to risks, benefits, and alternatives

Consent forms executed

Equipment, supplies, and staff prepared for procedure

Preventing Surgical Mishaps

History and physical exams completed

Pre-anesthesia assessment conducted

Correlation of pathologic and diagnostic findings

Vital signs and surgical site assessments continuously monitored

Discharge and Follow-Up Care

The premature discharge of a patient is risky business

The intent of discharging patients more expeditiously is often a result of a need to reduce costs

Discharge instructions must be clear and complete

Discharge and Follow-Up Care: Examples

Untimely Discharge

Failure to Provide Follow-Up Care

Failure to Follow-Up on Test Results

Abandonment: unilateral termination of a physician patient relationship by the physician without notice to the patient

Abandonment

Elements necessary to recover damages:

Medical care unreasonably discontinued

Discontinuance against patient’s will

Failure to assure follow-up care for patient

Foresight: Failure could result in patient injury

Actual harm was suffered by patient

Infections

Hospital acquired infections are a big problem

Nearly 2 million a year with 90,000 deaths

Fact that a patient contracted an infection will not in of itself cause a surgeon to be liable

Failure to effectively manage infection

Poor infection-control technique

Cross-contamination

Improper sterilization

Preventing spread of infection

Psychiatry

Commitment

Electroshock

Duty to warn

Suicide

Psychiatry

Commitment

Patient due process rights

Perform appropriate assessment prior to commitment

Two physicians to certify the need for commitment (separately)

Substantial danger of injuring oneself or third persons

Prove by clear and convincing evidence

Psychiatry

Duty to warn: when a therapist determines or reasonably should determine that a patient poses a serious danger to others, there is a duty to exercise reasonable care to warn and protect foreseeable victims

Suicide: duty to exercise reasonable care to protect suicidal patients from foreseeable harm

Fail to check on patient every 15 minutes as required

Restrained inadequately

Patient not examined daily as required by psychiatrist

Individual Exercise 1-Patient Safety

How common are these errors reviewed on the previous slides? What are the top sentinel events in the hospital setting? Research Joint Commission (joint commission.org)and Institute for Healthcare Improvement (IHI.org)

What are some factors contributing to these errors?

What outcomes do they lead to (ex: what types of adverse events, mortality rate, cost, etc.)?

How should this problem be addressed (ex: best practices)?

Principles of Medical Ethics: Code of Medical Ethics

Principles adopted by the American Medical Association are not laws, but rather standards of conduct that define the essentials of honorable behavior for the physician

A physician shall be dedicated to providing competent medical care, with compassion and respect for human dignity and rights.

A physician shall uphold the standards of professionalism, be honest in all professional interactions, and strive to report physicians deficient in character or competence, or engaging in fraud or deception, to appropriate entities.

Principles of Medical Ethics: Code of Medical Ethics

A physician shall respect the law and also recognize a responsibility to seek changes in those requirements that are contrary to the best interests of the patient.

A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

A physician shall continue to study, apply, and advance scientific knowledge; maintain a commitment to medical education; make relevant information available to patients, colleagues, and the public; obtain consultation; and use the talents of other health professionals when indicated.

Principles of Medical Ethics: Code of Medical Ethics

A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care.

A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.

A physician shall, while caring for a patient, regard responsibility to the patient as paramount.

A physician shall support access to medical care for all people.

Physician–Patient Relationship

Personalize treatment

Conduct a thorough assessment

Develop a problems list and comprehensive treatment plan

Provide sufficient time and care to each patient

Request consultations when indicated and refer if necessary

Physician–Patient Relationship

Closely monitor patient progress

Make adjustments to treatment plan as the patient’s condition warrants

Maintain timely, legible, complete, and accurate records

Do not make erasures

Do not guarantee treatment outcomes

Provide for cross-coverage during days off

Physician–Patient Relationship

Do not over-extend your practice

Avoid prescribing over the telephone

Do not become careless because you know the patient

Seek the advice of counsel should you suspect the possibility of a malpractice claim

Maintain the patient’s privacy rights

Physician–Patient Relationship

Relationship ends when:

Mutual consent of the parties

Patient’s dismissal of the physician

Physician’s withdrawal from the case

Agreement that physician’s services are no longer required

How does this relationship work?

https://www.youtube.com/watch?v=lBcMYGdrTMU

Discussion – what can patients do to enhance the physician-patient relationship?

Nursing and the Law

Scope of Practice

Permissible boundaries of practice for healthcare professionals

Statutes define the actions, duties, and limits of nurses

Role of nurses expand

Shortage of primary care physicians

Ever-increasing specialization

Improved technology

Public demand

Expectations within the profession itself

Nursing Diagnosis: States Recognition

Various states recognize that nurses can render a nursing diagnosis.

Nursing Diagnosis: Case

Cignetti v. Camel

Physicians ignored nurse’s assessment (diagnosis)

Contributed to delay in treatment and injury

Nurse testified physician told patient’s signs and symptoms

Were not associated with indigestion

Physician objected to nurse’s testimony

Physician stated: Statement constituted a medical diagnosis

Argument against nursing assessment

What was the court’s decision?

Nursing Diagnosis: Case

Missouri Revised Statutes (1975) authorizes an RN to make an assessment of persons who are ill and to render a nursing diagnosis. The Trial Court decision was affirmed

Nurse Licensure: Requirements for Licensure

Reciprocity

The nurse licensing board in one state recognizes licensees of another state

Endorsement

Boards determine if nurses’ qualifications are equivalent to their own state requirements at the time of initial licensure

Waiver

Nurses with equivalent qualifications can be waived in as licensed nurses

Examination

Some states make examination mandatory

Nurse Licensure: Suspension and Revocation

Violations may include

Procurement of a license by fraud

Unprofessional, dishonorable, immoral, or illegal conduct

Performance of specific actions prohibited by statute

Malpractice

Practicing without a License

Healthcare organizations are required to verify that each nurse’s license is current

The mere fact that an unlicensed practitioner is hired will not generally in and of itself impose additional liability unless a patient suffered harm as a result of an unlicensed nurse’s negligence

Nursing Careers

Registered nurse

Traveling nurse

Licensed practical nurse

Nurse manager

Certified nursing assistant

Float nurse

Agency nurse

Special duty nurse

Student nurse

Registered Nurse

A nurse who has graduated from an accredited nursing program, has passed a state registration examination, and is licensed to practice nursing

Traveling Nurse

A nurse who travels to work in temporary nursing positions in different cities and states

Licensed Practical Nurse

A licensed practical nurse (LPN), as well as a licensed vocational nurse (LVN), provides routine nursing care (e.g., vital signs, injections, assisting patients with personal hygiene needs, and wound dressings).

Under the direction of a registered nurse or physician

Nurse Manager

Chief nursing officer has responsibility for:

Maintaining standards of practice

Maintaining current policies and procedures

Recommending staffing levels

Coordinating and integrating nursing services with other patient care services

Selecting nursing staff

Developing orientation and training programs

Failure to supervise

Can lead to disciplinary action

Certified Nursing Assistant

A certified nursing assistant (CNA) is certified and trained to assist patients with activities of daily living.

The CNA assists with positioning, turning, lifting, and performing a variety of tests and treatments.

Cases

Failure to Follow Policy

Patient Fall

Patient Transfer

Leaving Patient Unattended

Float Nurse

Rotates from unit to unit based on staffing needs

“Floaters” can benefit an understaffed unit, but they also may present a liability if they are assigned to work in an area outside their expertise

If a patient is injured because of a floater’s negligence, the standard of care required of the floater will be that required of a nurse on the assigned patient care unit

Agency Nurse

Hospitals are at risk for negligent conduct of agency staff

It is important that the organization be sure that agency workers have necessary skills and competencies to carry out duties and responsibilities assigned by the organization

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