Prevention of Medical Errors: 2015

Transcription

1 Prevention of Medical Errors: 2015 David L. Adelson, Esq. What will we cover? Root-Cause Analysis Error Reduction Error Prevention Patient Safety Most Misdiagnosis or Mistreated Conditions: Addiction Psychiatric conditions and drug diversion Cancer Wrong-site/patient surgery Surgical complications/errors Cardiac and abdominal Root-Cause Analysis (RCA) What it is Process Not an End Remedial AND Reactive What it is not Not Adjudicative Not a Finger Pointing Exercise Not Proactive or Prospective IT IS SYSTEMATIC 1

2 Root-Cause Analysis (RCA) What is needed for success? BUY IN Data Confidentiality - Frankness Assurances of No Retaliation Accountability Objective Measures Error Reduction Errors What are they? FS or adverse incident means an event over which health care personnel could exercise control and which is associated in whole or in part with medical intervention, rather than the condition for which such intervention occurred, and which: a) Results in one of the following injuries: 1. Death; 2. Brain or spinal damage; Errors Reduction What is an error - continued 3. Permanent disfigurement; 4. Fracture or dislocation of bones or joints; 5. A resulting limitation of neurological, physical, or sensory function which continues after discharge from the facility; 6. Any condition that required specialized medical attention or surgical intervention resulting from nonemergency medical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent; or 7. Any condition that required the transfer of the patient, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the patient s condition prior to the adverse incident; 2

3 Errors Reduction What is an error - continued a) Was the performance of a surgical procedure on the wrong patient, a wrong surgical procedure, a wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the patient s diagnosis or medical condition; b) Required the surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process; or c) Was a procedure to remove unplanned foreign objects remaining from a surgical procedure. Let s take a breathe.... Why spend so much on a definition of error or adverse incident? The definition suggests means of reduction and prevention. 3

4 And, then there is the law.... Disclosure is legally required in Florida. FS Duty to notify patients Every licensed health care practitioner shall inform each patient in person about adverse incidents that result in serious harm to the patient. Notification of outcomes of care that result in harm to the patient under this section shall not constitute an acknowledgment of admission of liability, nor can such notifications be introduced as evidence. History. s. 8, ch Taxonomy of Errors Diagnostic Treatment - Delay Surgical Technique Medication Equipment Systematic Information/Education/Consent 4

5 The Most Dangerous Place THE HOSPITAL But Why? Joint Commission s Answer 2013 National Patient Safety Goals Different Goals for Different Practice Sites - Facilities Hospitals Ambulatory Misdiagnosis or Treatment of Addiction or Mental Illness - In two words Improvident Prescribing Prescribing without medical justification Prescribing to known addicts Failing to properly diagnose mental illness Treating anxiety or depression with inappropriate drugs 5

6 CANCER Lung Cancer Misreading X-ray Lack of Follow-up Breast Cancer Ditto Poor Record Keeping Importance of Biopsy Role of Reimbursement CANCER Prostate Failure to Diagnose - PSA Lack of Follow-up Treatment Misadventures Colorectal Failure to Diagnose Poor Record Keeping Wrong Site Wrong Patient Surgeries Wrong Site OR no place for assumptions or guessing Grounds for Disciplinary Action Check re-check and re-check Again Wrong Patient Never trust the patient 6

7 Surgical complications/errors and preoperative evaluations A nick here, a tear there Knowing when to go back in Infection Bleeding Prescribing, dispensing, administering, or using non-fda approved medications and devices Rationale FDA Questions You may contact me at or via at DAdelson@DrLaw.com 7