Patient Safety and Quality Initiatives

Understanding Errors in Medicine Diagnostic Errors   40,000 to 80,000 deaths result from misdiagnosis annually in the United States (MKSAP 16) Tort claims for diagnostic errors are twice as common as claims for medication errors (MKSAP 16) Approximately 40% of malpractice payments in 2003 were related to diagnostic errors (MKSAP 16) Examples:  Missed Diagnosis Pulmonary Nodule  Follow up is not arranged AKI that has resolved  Patient who have had AKI in the past are at risk of CKD  Adrenal Incidentoloma are not noted Delayed Diagnosis LBBB is not recognized as STEMI equivalent  Deconditioning and weakness not recognized on time (affects intervention timing and hence the recovery) Poor nutritional status of the patient is not recognized on time  Not recognizing the gait instability (in elderly or ataxic patients) Often times leads to fall during hospitalization  Wrong Diagnosis  COPD exacerbation is treated like ACS rule out when main presentation is SOB Pneumonia treated like HF (often when Pneumonia leads to MI leading to HF) Osteomyelitis treated like simply cellulitis   References Jumping to the wrong conclusion NEJM 1998 Improving Diagnosis in Health Care: Highlights of a Report From the National Academies of Sciences, Engineering, and Medicine Annals 2016 Diagnostic Errors  Diagnostic Errors type: If it is not in your Differential Diangosis, you will most likely miss the diagnosis.  Heuristics Errors: Availability Heuristic: Recently seen patient rather than most probable diagnosis Anchoring Heuristic: Premature closure of diagnosis Patient with COPD, HF, presents with SOB. Was not taking lasix. Diagnosis of HF exacerbation was made. In-fact patient had COPD exacerbation.  Due to lack of physician exam: Chest Expansion, Air movement (relying only on presence of absence of wheeze for diagnosis of COPD) Using Baysian Theory: Using pretest probability of a diagnosis to a post-test probability of a diagnosis. Helps you avoid errors just based on one clinical findings Work up for elevated Troponin is a perfect example. All elevated Troponin are not ACS.  Presentation for Back Pain: Staph Bacteremia, and not a slip disk  Representative Heuristics: Fits certain pattern Not completing a differential diagnosis including "worst-case scenario" Headache in a patient with recent separation from wife, and other family stressors. Tension headache diagnosis was reached despite the concern that  Utilizing time outs Ask Why:  Patient with COPD or CHF Exacerbation, we do not routinely answer a question why.  DKA: We do ask the question why, but once we find the answer, we do not go far enough to help resolve that question Lack of appropriate Physical Exam SJS skin lesion CHF vs COPD  Not listening to the patient Smiley: In severe Pain: Nec Fas Smalls: Severe tenderness on exam: Nec Fas Presentation for Back Pain: Staph Bacteremia, and not a slip disk  Relying on the not so good test to conclude the diagnosis Headache with Cerebral Vein Thrombosis. Two errors: CTA does not rule that out. MRI should have been ordered.  Incomplete DDx: Secondary headache suspected, but Cerberbal Vein Thrombosis was not in the DDx Diagnostic Reasoning and Diagnostic Error : ACP 2016  How do we think?  Pattern Presentation: Personal Pattern Processor  Type 1 Reasoning: Shingels  Type 2 Reasoning: Active analytical reasoning. Eg. Ocular melanoma causing Jaundice  With more clinical practice, Type 2 reasoning changes to Type 1 reasoning  Expert problem solver  Content specificity (GI vs Derm lesions) Context specificity : This matters.  Derailed by content specificity  Individual factors matters:  Environment matters  Loud Busy ED vs Quiet slow ED  Time to see patient Patient factors  Diagnostic Errors: No Fault (7%)  Patient related error  Example: Cocaine uses, BZD users,  System related errors (19%)  Technical Failures:  Faulty test or Data  Organizational Failures Poor EMR Inadequate supervision of trainees Poor communication  Overwhelmed clinicians Cognitive errors (28%) Faulty Knowledge: If not in DDx, you will not make a diagnosis Faulty Data Gathering Failure to ask Failure to examine Breast cancer  Prior records  Faulty synthesis Premature closure  Misjudging the importance of a finding  CT abdomen shows no appendicitis  Faulty context generation : Takes time and effort  Affective Error  Metacognitive failure : If subconscious influence is on your thought process by your previous experiences  8 ways to reduce diagnostic errors: IOM report from 2015 September  AHRQ funded research in diagnostic error   1. Increase awareness / experience  Mechanics of diagnostic reasoning Common traps / biases Being skeptical of own / others 2. Improving Intuitutive reasoning  Feedback on diagnostic reasoning : Unlike feedback on A1C, LDL etc Feedback needs to be on good, and bad, routine, remarkable, boring, noteworthy  Coached  3. Improving analytical reasoning Recognize your risk of bias and make your self think twice Diagnostic time outs Check List Presentation check list (eg. for Chest Pain) General diagnostic check list (complete history, physical exam) Take time to pause and reflect SAFER Serious Diagnosis Alternative Diagnosis Feeling affecting thinking Extraneous data .. is it really extraneous..WBC?  Reasons for why this happened?  Be a skeptic? Bayesian analysis  4. Improve the context  Radiology rounds? Pathology rounds ? Talking to the PCP? Discussing patient with consultants instead of waiting for the note? Number of patients you see? Improving the atmosphere?  As a diagnosticians we need Time with patients Time to review Time to think Medication Errors Between 500,000 and 1.5 million preventable adverse drug events occur each year in the United States, with an estimated 1 medication error daily for each hospitalized patient. (MKSAP 16) Examples:  Drug interactions  Dose adjustment in impaired kidney or liver function or in elderly (MKSAP 16) Medications are prescribed, but patient does not receive it (eg. Antibiotics) Medications are prescribed at wrong dose at wrong times (eg. Anti-hypoglycemics) DVT and GI prophylaxis are not provided in appropriate patients GI Bleeding: Not on GI prophylaxis   Wrong medications are selected Infectious etiology - Bactrim is given when it is more likely Strep Cellulitis (Bactrim has lower potency for Strep Gp A) DAPT is not given while conservative management of the UA  BB and anti-coat are sometime missed during ACS management Wrong dose and duration of medications  Infectious etiology Fluconazole for Thrush vs Esophagitis  Vancomycin dose in the presence of bacteremia and previously high MIC  Transition of Care related Errors  20% of patients discharged from the hospital will suffer an adverse event related to medical management within 3 weeks of discharge, 2/3rd  are related to medications. (MKSAP 16) Medication discrepancies increases 30 day readmission - 14 % vs 6 % in elderly pt: 14 % of elderly patients with medication discrepancies between prescribed outpatient and discharge medications are rehospitalized within 30 days, compared with 6% of those without medication discrepancies. (MKSAP 16) Pharmacy led med reconciliation - 1 % vs 11 % adverse events at 30 days of discharge: When medication reconciliation efforts are led by pharmacists, the rate of adverse drug events at 30 days is 1% versus 11% in control patients. (MKSAP 16) Timely follow-up with a PCP after hospital discharge, particularly within 1 month, leads to lower rates of rehospitalization. (MKSAP 16)  DC Summary does not reach to PCP on timely fashion. And, often, is incomplete.  Other sources Patients understanding of the illness is not fully assessed In such patients, enough attention is not paid to ensure reliable alternatives to ensure medication adherence, timely follow up, rehabilitation In patients who are unable to do their ADL, dc planning is often incomplete and inaccurate  Additional Reading Readmission Diagnoses After Hospitalization for Severe Sepsis and Other Acute Medical Conditions JAMA 2015 Transitions of Care In the Clinic Annals of Internal Medicine 2013 Transitions of Care In the Clinic Annals of Internal Medicine 2013 Other preventable harms to the patient during hospitalization Healthcare associated Infections CAUTI due to unnecessary use of Urinary Cathetor  IV access related blood stream infection  Fairly good number of PICC lines are unnecessary. Often leads to DVT and Catheter associated infections  Good Hand Hygiene can prevent many of these situations  Hand Hygiene (VIDEO) NEJM 2011 WHO Guidelines on Hand Hygiene in Health Care (2009) CDC Presentation on Hand Hygiene  Ordering unnecessary tests  CT Scan in a patients when it is not needed (especially with Contrast) Contrast extravasation can lead to harm  Ordering MRI when not necessary Delays the MRI on an otherwise appropriate patients causing delayed diagnosis and prolonging the hospital stay  MEDICAL COST of Various Tests  Healthcare Bluebook Hands off: Safe Transitions, Reducing unnecessary readmissoins Some reports mentions that 70 % readmissions are preventable  PCP not being aware is the major risk factor for readmission Verbal communication is the Key (Automated when possible) Checklist or Computer generated discharge  Majority of the process are Swiss Cheese Model  TOC Model Transition Care Model: Mary Naylor: 3 nth follow up by Nurse to home; 1000 / pt Care Transitions Model : Erick Coleman: Home visit by layperson over 30 days: 200 / pt Project BOOST: SHM;  Checklist. 7 points (7 P - ... Cost Minimal Project Re-engineered Discharge (RED) : Boston University - Muticomponent - unclear cost  Issues of financing care coordinators  Advantages / Disadvantages of Hospitalists: Econonmis of specialization  Advantage: Expertise in in-patient care Disadvantage: Loss of Dr-Pt care Balancing this is the key  What can be done Identify the most common readmissions and focus the effort on such patient  Emerging Models Comprehensive Care Model See highly complex patients only AM in hospital PM in clinic Much smaller patient panel due to the complexity of patients  Expected hospital stay / year > 10 days  Results: CCP Panel: 200 patients; 3-4 inpatients  Top 10 Medication Errors  Quinolones Peripheral Neuropathy  Tendon Rupture in shoulder, hand, and achilles tendon Risk Factors: On steroids, and quinolines in older patients  Possible associated with Aortic Disease  Collagen associated Adverse events  Tendon Rupture Retinal Detachments ?  Aortic Aneurysm  Delirium Arrythmia in  a patient with QTc prolongation  Hence: Not indicated for acute bacterial sinusitis, uncomplicated UTI,  Sitaglipitin (DPP4 inhibitors) Polyarthropathy with DPP4 inhibitors  33 cases identified related to this ; 10 requiring hospitalization  All pain resolved on stopping DPP4 inhibitors Zolpidem  Non AD (OR of 1.33) , Especially when it is due to use of higher doses use Unclear if those patients who were using higher doses also had worse insomnia that may have contributed to insomnia BZD and few others Hypnotic Drugs increase Mortality but was not seen in case of Zolpidem  Increased risk of fall was seen with Zolpidem  NSAIDs and MI  Denmark HR of death with NSAIDS 1.59 at 1 yr FDA has sternghted the warning of CV risk with NSAIDs Increased risk of HF: especially with longer acting NSADs PPI  Risk of CKD JAMA 2016 HR of 1.5 BID use associated with higher risk  Risk of Dementia ?  HR of 1.4 Decreased Ca absorption  Decreased Iron absorption Increased fracture risk  Decreased thyroid absorption Decrease Magneusium absorption Poor B12 absorption Increased risk of C diff and recurrent C diff SGLT 2 inhibitors Risk of euglycemic ketoacidosis (likely due to decreased Insulin production due to low glucose, causing relative hypoinsulinemia) Statin Statin Myalgia more prevalent in patients with Vit D deficiency N Am J Med Sci 2015, On giving high dose Vit D to level > 50 , lead to 95 % patients free of myalgia  Rhabdomyolysis (rare:: 0.01%) Liver failure (0.0001%) Myalgias 5-18 % Check CK, TSH, VItamin D Stop and when stops resolve, restart at lower dose  If recurrent, Try Flucastatin or low dose rosuvastatin If persistent, try ezetemibee Cataracts? Diabetes  J Gen Internal Med 2015 30 (11) Diabetes Care 2014; 37; S14-S80 1 new case per every 255 patients Cognitive impairment CoQ10 Does not work for muscle pain or CK levels (Mayo Clinic Proc) SSRI  Hyponatremia is a risk in a patient with Older age Female Concomitant diuretic use makes risk much higher  Low body weight  Hyponatremia HCTZ SSRI SNRI NSAIDS MDMA (ecstasy) TMP-SMX Hyperkalemia occurs, with increased risk of Sudden Cardiac Death Much higher risk if on ACEI / ARB Antibiotics and increased risk of SCD TRM/Sulfa Quinolones Azithromycin Drug interaction  Clarithromycin and Statin, Gemfibrozil, Increased Statin Toxicity Fibrates (15 X) Azoles antifungals Amiodarone Erythromycin / Clarithromycin (not azithromycin) Protease Inhibitors Verapamil / Diltiazem (less with amlodipine / nefedipine except with simva) Least DI with Rosuva and Prava, mot with Simvastatin, and lovastatin If taking concurrently, space in time may help  Warfarin Most severe TMP / Sulfa Amiodarone Azinthromycin, Levofloxacin, TMP/SMX all increased INR

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