In November 1999 the Institute of Medicine (IOM) issued the report To Err is Human, detailing a problem of preventable medical errors that were killing as many as 98,000 inpatients per year. Specific types of medical errors highlighted in the IOM report include error in the administration of treatment, failure to order and follow-up on indicated diagnostic exams, and avoidable delays in care and treatment. Many years later problems still exist: nearly 2 million patients a year develop infections during their hospitalizations, and 90,000 to 100,000 of those infected die while hand-hygiene rates range from 30%–70% at most acute care facilities. The IOM report also estimated that medical errors cost the U.S. $17 billion to $29 billion a year, and called for sweeping changes to the health care system to improve patient safety.

Improvements in patient safety have focused on addressing the root causes of these preventable patient harm events, specifically events related to poor communication, lack of teamwork, fragmentation of care, and a lack of leadership from the medical community. In addition, patient safety experts have also implored physicians and hospitals to approach patient harm events with transparent, open, and honest communication between caregivers and patients and families in order to learn from mistakes and poorly designed systems.

This chapter focuses on the important ways in which hospital-based physicians can actively participate in the prevention of patient harm and provide appropriate management and assistance when patient harm does occur.

While there are many important ways that hospital-based physicians can proactively maximize the safety of their patients, most patient safety experts would agree that the areas of highest priority can fit into three broad domains: communication, teamwork, and leadership (see Table 35-1). Within each of these domains lies critical concepts and issues about which the highly reliable and safe-practicing physician must remain mindful.

Communication

No chapter on patient safety and the prevention of patient harm is complete without a major focus on the role communication—or lack thereof—plays in serious patient safety events. The most common types of communication of high priority in patient safety are listed in Table 35-1.

Handoffs

Year after year The Joint Commission (TJC) publishes data showing 65–70% of all sentinel events are rooted in communication breakdowns. It appears that since the implementation of the Accreditation Council for Graduate Medical Education (ACGME) resident physician work hour limitations the communication problems have increased, especially in the area of handoffs, when the responsibility of care is passed from one provider to the next. With this limitation of resident physician work hours the need and demand for hospital-based physicians to “fill the gaps” in patient care has increased substantially. Associated with that increase in demand, hospitalists in particular have recognized the imperative of a standardized, user-friendly, and reliable method of handing off care from one provider to the next.

The content and process for handing off in the inpatient setting has evolved as practitioners try to meet regulatory requirements while maintaining simplicity, efficiency, and usability of the various handoff tools that are available. Various pneumonic tools, such as Situation, Background, Assessment, Recommendation (SBAR) have been devised to assist in the handoff process but have come and gone from institutional policies and guidelines as providers struggle with a reliable way to meet this important imperative. Hospitalists must play a role in designing and implementing a best practice handoff process appropriate for the context in which they work.

Vendors of electronic health records (EHRs) have also entered the arena with HER-based tools to facilitate the often onerous process of handing off care of large numbers of patients. Regardless of the chosen method, all hospital-based physicians must employ a reliable process to transmit necessary patient information from physician to physician. Defective or unreliable handoffs substantially increase risk of patient harm and the associated liability.

Documentation in the Electronic Health Record (Ehr)

With the passage of the 2010 Health Care Reform Act, it has become increasingly clear that the use of electronic health records will become much more ubiquitous in the coming years. While patient safety benefits of EHRs are well documented, only recently have informatics experts been publishing the unintended, unsafe consequences related to their use.

One of the most glaring examples of an unintended, unsafe consequence to EHR implementation is the abuse of “cut and paste” or “copy and paste” functionality, the process by which entire sections of nursing or physician documentation are copied and pasted from past to present notes. Numerous published reports demonstrate cases in which erroneous information has propagated, almost “virally,” throughout a patient’s EHR through the use of copy and paste. This process creates unsafe conditions for the patient such as in the example of the erroneous propagation of a “faux” allergy to an important medication. Serious medical-legal consequences can result for those who continue to misrepresent medical information through subsequent “copies” of the erroneous information or for those who act upon this unreliable information. The credibility of physicians comes into question when they are forced to defend misinformation they have propagated throughout the medical record, such as a temperature of 1101.5 F or a blood pressure of 1180/60.

While the “copy and paste” functionality provides useful efficiencies for documentation of long lists of medications or past surgical procedures, hospital-based physicians must be aware of the deleterious consequences of the inappropriate use of this functionality and they should serve as positive role models and mentors throughout the organization for others who document in the EHR. From a patient safety and legal perspective, it is also incumbent upon the hospitalist to facilitate the correction of erroneous information encountered in the EHR.

Management of Critical Test Results

Critical-test results management cuts to the heart of the health care business. U.S. hospitals complete approximately 12 billion diagnostic tests every year. Most test results are within normal range and do not require follow up by the clinician. However, a small but important number of test results, approximately1% to 5% of a hospital’s test volume, are abnormal or critical. Hospitals and hospital-based physicians have a professional, legal, and ethical obligation to ensure that these results are communicated to the responsible physician and appropriate action is taken.

Traditional systems to communicate and manage critical results are full of potential points of failure. In many hospitals, especially for hospital-based physicians, contact information changes on a regular basis. Radiology departments and the pathology lab may not have the correct contact information for the responsible physician. Faxes can be equally problematic as the receiving machine might be off or out of paper. And once communicated, the right person might not receive the information. Unfortunately, radiologists and laboratory technicians may spend hours or days trying to track down the appropriate physician for results communication. Not surprising, miscommunication of critical findings have been identified as the causative factor in 85% of radiology lawsuits. Appropriately, The Joint Commission (TJC) has deemed the management of critical test results as a national patient safety priority and requires hospitals and health care professionals to improve processes involved in such results. To improve the safety and quality of care their patients receive, hospitalists must play an integral role in the design and implementation of systems and processes to manage critical test results. At a minimum, in the hospital setting they must actively participate in a process to ensure the proper identification of responsible physicians and an efficient means for involving those responsible physicians in the communication and action based upon these results.

Teamwork

Multidisciplinary Rounds

Data abounds on the value teamwork brings to the safe and effective delivery of health care. The days of a single physician effectively micromanaging a patient’s entire hospital stay are long gone. Research has shown that physicians can mitigate the negative effects of the necessary fragmentation of health care delivery by participating in multidisciplinary rounds during which physicians, nurses, pharmacists, and other allied health professionals discuss the daily plan for the patient and coordinate the transition of care to the outpatient setting. Inclusion of the patient and family in these rounds also provides benefit.