Why not put adverse events right in patient charts?

I’m a second year medical student at the University of Missouri, and I’m currently working at an internal medicine practice in St Louis. I’d like to share a recent patient safety story with you.

The patient was an elderly gentleman who had been a long time patient of the doc I’m working with. He had a heart attack a few years ago and has been seeing a cardiologist since then. He recently began experiencing chest pain on exertion, so he went to the cardiologist for an angiogram and possibly angioplasty. He needed two stents.

He had an appointment with us about a week after his angioplasty, and I reviewed the cardiologist’s report before interviewing him. After reading a summary of his blocked arteries and location of the stents, I was shocked (in a good way!) to see this addition at the end: “Adverse event–catheter pierced a small coronary artery. The patient was stabilized and appropriate treatment was administered. The patient remained overnight for observation. We will follow-up in clinic in three days.”

I asked the doc I was working with what he thought of this report. “Well, there’s no reason to hide it if something went not according to plan. People generally like it if you’re honest with them, treat them fairly, and tell them about how you’ll avoid this in the future.” The patient wasn’t angry; he didn’t file a lawsuit; he still uses the same cardiologist.

Next, I went in to see the patient. I asked him about his heart and how his angioplasty went. He smiled and said, “Oh, it was fine. I have two new stents. There was a minor mishap, but I’m OK now.”

Sure is nice to see the principles I learned at Telluride in action!

-Kristin Morrison, University of Missouri

(APPLE Allies, the “author” of this post, is a nonprofit organization I started. We’re working to improve health literacy in mid-MO. Check out our blog!)

Post Telluride Reflections (Part 2): Renewed Faith by Julie Morrison #TPSER8

There is nothing more powerful than a personal experience. Helen Haskell represented this at the Telluride Patient Safety Roundtable. Her son, Lewis, died of medical misdiagnosis which inhibited the team from providing appropriate life saving treatment, his story was recounted in a video produced by Drs. Mayer, McDonald and the team at Solid Line Media. The story and the courage Helen has to continually attend the conference and provide a first-hand experience of an unsafe medical system was by far the most memorable things about the week. There were lots of memorable things about the week, including the views from the gondola required to scale the mountains and the dedication of the faculty members, but Helen’s story will continue to stay with me. I am hoping that her son’s memory can act as a guiding force for all of us. A memory we can return to when we have lost our way along the road toward patient safety. A memory that will guide us back toward putting the patient and family as the center of our care if we go astray due to personal, family, financial or others factors. In the beginning of medical school, I was astounded by how many of the students were truly good people, they were caring people with big hearts and understanding minds. Research shows that our empathy decreases as our medical education progresses and reaches a nadir by year 4. I can only assume that it continues to fall as we take on the responsibilities of internship and balance this with the desire and responsibility of starting a family, being a good son/daughter, neighbor and colleague. I hope that Helen and Lewis’ story counteract this passivity and continue to call us toward our original goal of helping others, which, as the Hippocratic oath correctly details, first requires us to do no harm.

On neurology rotation I saw a case that exemplified a large number of the topics we discussed at the Telluride Roundtable this year. This was the case of a 71-year old woman that came in for an outpatient endoscopy with dilation for a post-surgical esophageal stricture. During the procedure she desaturated and was intubated within minutes. The procedure was suspended and physical exam at the time showed no apparent life threatening abnormalities. Within 2 hours the physical exam showed anisocoria with the right pupil dilated to 4 mm. A stat CT scan of the brain showed “bubbles” within the cerebral veins as well as extensive cerebral edema and evidence of an uncal herniation with compression of the left cerebral peduncle. Mannitol was run, the head of the bed elevated to 30 degrees, a central line was placed, the ventilator settings were changed to hyperventilation protocol and an FiO2 of 100%, and an extra ventricular drain was placed. Despite these measures the patient continued to develop cerebral edema and had intracranial pressures into the triple digits throughout the night, she was declared dead by brain criteria the following day by our team.

I went home and cried that night. I was shocked by the thought that someone can come into the hospital thinking they are getting a benign routine procedure and die from massive cerebral edema within hours. The patient’s husband was in the room the entire time; he was so strong to stand beside her during the interventions and stronger still for his open attitude toward the hospital staff. Luckily he was not angry or resentful of the staff, and believed that they did everything in their power to save his wife. This is lucky for him, but also for the hospital because I don’t think our staff is equipped to manage such events. I was waiting for the “safety officers” to come debrief the husband and explain the situation to him, I was counting the 15 minute deadline that they had and wondering how their involvement would have changed the course of events. I realized that these professionals could have a dramatic calming effect on the entire care team. During the intensive bedside interventions the team was perplexed by the etiology of the patient’s neurological deterioration. Many nurses were asking, “what happened” “what’s our story” “what should I tell the patient’s husband” and no one took the leadership role to answer these questions. In truth, no one knew the answer but no one stepped up to simply say, “we don’t know but let’s focus on stabilizing the patient and then we will investigate the cause.”

I call this a poor outcome rather than an error because our attending found a report of 20 such cases in which air embolic strokes occurred during or after procedures that require insufflations (endoscopy, laparoscopy, colonoscopy etc). This then becomes a rare but known complication of the procedure which made me think of the informed consent conversation we had during the roundtable and of Michael Skolnik. I was fairly sure that no one informed the patient of the risk of air emboli infarcting her brain. The pathogenic theory is that microscopic tears in the viscera allowed air to enter the esophageal veins, traveling to the IVC and through the lung vasculature to the systemic circulation (via pulmonary arterial-venous shunts). We believe that the patient’s desaturation was secondary to pulmonary emboli from the same mechanism. Does this a represent a reasonable risk that the patient deserved to be notified of? I don’t know. Twenty cases is not a large number, but the published case reports most likely underestimate the true incidence. Would I have wanted to be informed of this prior to the procedure? I don’t know. I would have had to weigh the risk against the potential benefit. This is the essence of shared decision making –giving the patient the facts and allowing them to ascribe their value assessment onto those facts and arrive at a logical decision. Without knowing this patients baseline I was left feeling only sad for the outcome and the loss of innocence that occurs when something so precious is lost- a life and a trust in the medical community.

I am glad that the patient’s husband did not see it this way, I am glad that he maintained respect for, and trust, in the doctors caring for his wife. When my grandmother died of hepatic failure after taking the antibiotic Trovan ®, and the drug was subsequently pulled from the market due to risk of liver toxicity, I started to question my faith in the medical community. I became committed toward the application of sound evidence to the relief of human suffering. My faith in the medical community was restored slowly over my first two years in medical school as I learned that most physicians operate with very good intentions but in a complex environment which is not readily transparent or controllable. The derogatory based jokes I heard during my third year (while I know not ill-intended) started to erode at that faith again. Attending the Telluride Patient Safety Roundtable completely renewed my faith in the medical community. I was inspired by the fact that such successful professionals take the time to teach medical students basic leadership and patient safety goals. In every conversation and action I could tell that they had the patient’s best interest as their primary goal. They renewed my faith in the medical community not only because they are true role models –individuals that I aspire to emulate, but also because they taught us how to lead the medical community into a more respectful patient driven culture, and I now know we can do it!

Post Telluride Roundtable Reflections: Process Improvement-Real-Time Results by Julie Morrison #TPSER8

Upon returning to UT medical center from Telluride, I was filled with motivation and a new sense of purpose. Something had changed in me out there. I used to be more of a ‘thinker’ (forever told I would be good as an internist) and not so much of a “doer.” I struggled with this during my third year of medical school because I saw so many areas of improvement but often sat near the sidelines gathering information rather than jumping in and stimulating change. At Telluride I was so encouraged by the perspective of the senior faculty; the fact that they found similar aspects of the clinical world frustrating or inefficient and were looking for a collaborative team to face these challenges reinforced my perspective and encouraged me to take action. Telluride gave me a better vision of the organization and hierarchy of a hospital as well as the tools to accept such a call to action. I realize now that a vision cannot be translated into change without the support of various members of the care team and hospital administration. A good idea can fester forever within someone without ever seeing the light of day or be implemented without the correct support and flop because of a lack of motivation or proper support.

On the third day of the conference, we broke into small groups and discussed real life changes we would like to see in our hospitals. My team came up with a “bedside communication white board” that would list the care team (nurse, attending, residents, medical students, PT, OT, RT etc), their expected procedures and daily care plan. It would also serve as a place for the patient or their family to list questions and concerns. We envisioned that this tool would empower the patient to engage in their healthcare by making them informed participants and serve as a stop-gap from wrong procedures. When I returned to campus I was excited to stimulate change but tempered this excitement in order to stimulate the proper support for my ideas, as I didn’t want to be run over by resistance. I scheduled a meeting with the CMO of our hospital system and settled into my clinical rotation.

The first day I spied portrait covered papers in several patient rooms before a nurse manager came by and left a stack on the cart we were using for rounds. I immediately picked them up and found a paper form of our “bedside communication white board!” I almost couldn’t contain my excitement. I followed the nurse down the hall and asked her about this innocuous sheet she left. We engaged in a great conversation and she invited me to sit in on the quality improvement meetings that she attends. I took over the responsibility of filling out these sheets for each patient as we rounded for the rest of the week. I did so silently at first. And then I started getting questions from the other members of our team. In the past I would have been uncomfortable explaining my actions, I would have been concerned that it wasn’t a big enough idea, or that they would find it frivolous or frustrating. But not now; because of Telluride and the perspective of the senior faculty I spoke with confidence and clarity of vision. I knew that this tool would make a difference and I educated the other students, residents and even our attending so that they could see its value as well. By the end of the week I was receiving really good feedback from the patients having them say things like “oh I was waiting for this” or “this is so helpful, thank you” and even had the senior resident thank me for utilizing the sheets. I think it is going to stick, and I think we will have it implemented across the hospital by the winter!

Post Telluride Reflection by Matt Starr #TPSER8

I finally was able to get my burrito, but not without trouble. We showed up to town after a long afternoon of biking down the mountain around 5 pm. The problem with that is the taco stand closes at 5 pm. So I raced over to the stand only to find it closed, but the back door, which also served as the entrance, was still open. I ran up to it and asked the man inside if he would make me anything that he hadn’t put away for the day or ran out of. He agreed and made me a burrito and I had no idea what was in it, but I loved every bite. I cannot wait until I get to come back to Telluride again, this place is by far one of my favorite places to visit in the world; the people, the food, the atmosphere, it is truly an amazing place.

My ‘aha moment’ happened when Tim pointed out to me the obvious distinction between the airline industry and medicine. Yes, hospitals should be more like the cockpit, but every time a pilot makes a mistake, it is most likely going to cost that pilot his/her life. However, if a physician makes a mistake, it will most likely cost that patient his/her life. That is why the airline industry has always been faster at implementing change, they major stakeholders in the decision making process are risking their livers with each error being made.

Dr. Angood had been hinting to me all week the problems associated with this kind of standardization in medicine. Medicine and aviation are very similar, but also very different. Every medical case is different in some aspect than the previous. It can be very beneficial to streamline the major processes, but the doctors can’t be afraid to deviate from the standardization because it is very hard to categorize each patient that comes into the hospital into distinct groups.

This past week was a great opportunity to meet some really great people while learning about patient safety. I can’t speak for everyone, but I think most of us really made some great friends here and created a network that will allow us to transform our medical schools and hospitals into safer institutions. I learned a great deal about the current problems the field of medicine faces in terms of patient safety. It seems that every field can improve greatly and every allied health profession (nurses, PTs, OTs, PAs, etc.) can greatly improve…that’s a lot of room for improvement. But I think this conference was the first step in creating the network that we can all build on in the future as we seek to improve patient safety in all of our respected fields.

-Matt

See One, Do One…#TPSER8

There’s an old adage in medical education “see one, do one, teach one.” I don’t particularly subscribe to it in a literal sense because I think training requires a more intensive learning process than that.  But sometimes it does apply quite nicely.  A perfect example of this was on Wednesday when I helped run a session about shared decision making and informed consent at our new house staff orientation.  The session consisted of a viewing of the video of Michael Skolnik’s story followed by a moderated discussion with the house staff.  The idea came out of a casual conversation with my hospital’s Associate Vice President for Academic Affairs.  I thought it would be a helpful to new residents to think about these important issues before they really start on the wards and she let me run with it.   Just two weeks out of TPSER8, I just felt the itch to continue sharing what I’ve learned.  I had never led anything like this, but after seeing how David Mayer and Tim McDonald guided our discussion in Telluride I was inspired to try it myself.  I had some great help from a fellow Telluride alum, Hilary Kunizaki as well as several other CIR staff who came for the session.  Here are a few comments from the new house staff:

• I asked, “What do you do when patients don’t understand a treatment or procedure?” and had some great responses: “draw a picture”, “have someone else ask” and “figure out if there is a language barrier”
• In regards to the stereotype that general practitioners know less than specialists, the interns suggested that specialists should work with PMDs in a team-like manner, concentrate on common goals and the interests of patients, and verify information by referring back to the literature.
• There was some hesitance among  house staff who might be doing a procedure for the first time about admitting their inexperience to patients so I pushed them to consider an appropriate response.  Interns said they would tell patients that “they were under supervision and working with attending X who has x number of years of experience.”
• Important strategies to verify consent included the “teach-back” method, assessing capacity to make a decision, and involvement of family members.
• One intern said that “no one patient is an island” and echoed the consensus that involving family members is important even if the patient is over the age of being legally able to sign an informed consent document.
• Some difficulties that residents mentioned when performing informed consent include language barriers, time, and dealing with patients who are uncooperative.

Overall, the new house staff seemed to really enjoy having the opportunity to be engaged in a discussion rather than just hear a lecture about the importance of informed consent.  I think this further proved the importance of narratives in medicine.  I’m looking forward to holding more conversations like this in the future.

Connecting in Telluride by Belle Brennan

Every medical student should read “Why Hospitals Should Fly”. More than once. The book not only provides practical solutions to the real problems we identify at the heart of Patient Safety, but also provides a constant reassurance and motivation of why we are making those changes. Today’s brainstorming session took us all by surprise. For the first time this week, we all connected on a completely different level; we were able to acknowledge the strengths of a particular project, but also raise the hurdles to implementation. In a few hours we had really transformed our minds to see that the changes we want to see in healthcare are possible.

The hike and dinner provided much more informal settings for us to discuss these issues. What I love about a group like this is that a conversation between one student and either Dave or Tim quickly becomes a small group all bouncing ideas of each other and making real critical analysis of situations.

I wish every medical student had the opportunity to absorb even just a little of the motivation and energy I’ve obtained from Telluride. But without a doubt, every medical school across the Country should have that fantastic book on its compulsory reading list.

Day 3 Telluride Reflections–Denise Neal #TPSER8

The hike today was amazing.  We set our today at the bottom of the mountain with reservations of conquering the challenge ahead of us.  Some of us were unsure if we would make it to the top.  We already had moments of being short of breath just from the altitude.  The hike symbolized the challenges we will face as we move forward to implement change and increase patient safety.  At times we walked together; similar to when we are all in agreement with a change.  At times we also walked up hill alone, similar to when we do not have buy in for a change and we carry the burden to move it forward alone.  The journey seamed long at times and it was hard to know how far we had left to go, and felt unsure of how far we had come.  We took the climb one small step at a time and eventually we saw the end in sight.

We finished the day brainstorming ideas for change.  The group came up with many great ideas and solutions for change.  We discussed barriers that might get in the way and solutions to address these barriers.  We talked about identifying stakeholders in order to garner support for our patient safety solutions.  We also talked about measuring the outcome of the changes.  The group used creative ideas of how to share these solutions with other groups across the country.

Denise Neal