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Chapter 9: Patient Safety, Quality and Value Harry Burke MD PhD Learning Objectives After reviewing the presentation, viewers should be able to: Define safety, quality, near miss, and unsafe action List the safety and quality factors that justified the clinical implementation of electronic health record systems Discuss three reasons why the electronic health record is central to safety, quality, and value List three issues that clinicians have with the current electronic health record systems and discuss how these problems affect safety and quality Describe a specific electronic patient safety measurement system and a specific electronic safety reporting system Describe two integrated clinical decision support systems and discuss how they may improve safety and quality Patient Safety-Related Definitions Safety: minimization of the risk and occurrence of patient harm events Harm: inappropriate or avoidable psychological or physical injury to patient and/or family Adverse Events: “an injury resulting from a medical intervention” Preventable Adverse Events: “errors that result in an adverse event that are preventable” Overuse: “the delivery of care of little or no value” e.g. widespread use of antibiotics for viral infections Underuse: “the failure to deliver appropriate care” e.g. vaccines or cancer screening Misuse: “the use of certain services in situations where they are not clinically indicated” e.g. MRI for routine low back pain Introduction Medical errors are unfortunately common in healthcare, in spite of sophisticated hospitals and well trained clinicians Often it is breakdowns in protocol and communication, and not individual errors Technology has potential to reduce medical errors (particularly medication errors) by: Improving communication between physicians and patients Improving clinical decision support Decreasing diagnostic errors Unfortunately, technology also has the potential to create unique new errors that cause harm Medical Errors Errors can be related to diagnosis, treatment and preventive care. Furthermore, medical errors can be errors of commission or omission and fortunately not all errors result in an injury and not all medical errors are preventable Most common outpatient errors: Prescribing medications Getting the correct laboratory test for the correct patient at the correct time Filing system errors Dispensing medications and responding to abnormal test results 5 While many would argue that treatment errors are the most common category of medical errors, diagnostic errors accounted for the largest percentage of malpractice claims, surpassing treatment errors in one study Diagnostic errors can result from missed, wrong or delayed diagnoses and are more likely in the outpatient setting. This is somewhat surprising given the fact that US physicians tend to practice “defensive medicine” Over-diagnosis may also cause medical errors but this has been less.

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At least one in every 20 adults who seeks medical care in a U.S. emergency room or community health clinic may walk away with the wrong diagnosis, according to a new analysis that estimates that 12 million Americans a year could be affected by such errors. Experts have often downplayed the scope of diagnostic errors not because they were unaware of the problem, but “because they were afraid to open up a can of worms they couldn't close.

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zel ek Kaybetti Sammy Benson, Downtown Bank'n tek boyutlu, yabanc ve hasarl ekleri ileyen zel ek Tasnif Birimi'ni denetledi. ekler birimine gnderildikten sonra manuel olarak yorumlanp, kayt altna alnp ilgili hesap hareketlerine girilerek iade iin dosyalanmtr. Sammy, departmanndaki ek tasnif memuruna nezaret etti. Bu iler, liseden yeni mezun olmu, grece eitimsiz, giri seviyesindeki kiiler tarafndan yaplyordu. Yaz boyunca Greater Downtown Bank, Community Upbeat kampanyasnn bir paras olarak dk gelirli, dezavantajl genleri irket genelinde eitli iler iin ie ald. Bu abaya katlmak iin nsan Kaynaklar Departman temsilcileri seilen liseleri ziyaret ederek rencilerle grtler. renciler zaten okul tarafndan n elemeden geirildiinden, grmeler "tanma" tartmalarndan biraz daha fazlasyd. Geen yaz, Sammy'nin birimi bu abadaki ilerden birini salad. Juanita Perez, bu balamda zel Kontrol memuru olarak almak zere ie alnd. C ortalamasn koruduu yerel meslek lisesinden mezun olduktan sonra Haziran aynda almaya balamas planlanyordu. Bu onun ilk tam zamanl iiydi. Juanita ksa bir greve balama program iin bankaya rapor verdiinde korkmutu. Sadece iteki ilk gn deil, ayn zamanda bankaya ilk geliiydi. Yine de cesaretini toplad ve planlad gibi nsan Kaynaklar Departmanna rapor verdi. Lobide bir sre bekledikten sonra kk bir toplant odasna gtrld ve burada kendisine ve dier iki yeni ie alnan kiiye eitli formlar ve belgeleri nasl doldurup imzalayacaklar gsterildi. Daha sonra, bir idari asistan yeni ie alnanlara alma programlar, molalar, fazla mesai, maa gizlilii, devam ve yan haklar hakknda bir dizi personel politikasn okudu. Tm bunlarn ne anlama geldiini merak ederek daha fazla form imzalad. Toplant sona ererken, nsan Kaynaklarndan bir telefon aldktan sonra Sammy Benson geldi. O ve Juanita ilk kez tantrld. Sammy, Juanita'ya bankann eitli ofislerini ve dier departmanlarn gstererek nsan Kaynaklar Departmanna kadar elik etti. Ona blgesini hzl bir ekilde gezdirdi ve giderken onu dier katiplerle tantrd. Ancak Sammy ilerini blmemeye dikkat etti ve Juanita'ya ne yaptklarn aklamad. alanlarn onu grnce ardklar yzlerindeki ifadeden belliydi. Ksa bir tur ve birka ksa tantmdan sonra Sammy, Juanita'ya iiyle ilgili baz temel talimatlar verdi. Juanita'ya yabanc ekleri ileme koyma iini verdi. Bu grevin renilmesi ve doru ekilde yaplmas en kolay i olduunu dnyordu. teki ilk gnnde, Sammy ona prosedr gstermek iin yaklak 15 dakika harcad: inceleme, kaydetme, girme, ayarlama, dosyalama. O gn daha sonraki bir toplant iin hazrlanmak zorunda olduu iin, onunla geirebilecei tm zaman buydu. lk haftann sonunda, Juanita baz eyleri anlamaya balam gibi grnyordu: e zamannda geldi, meguld ve olduka hotu ve birlikte olmas kolayd. Sammy, bu dnemde onunla olabildiince ok zaman geirmeyi amalad; ancak, abucak anlyor gibi grnd ve adam ok megul olduu iin, onu sonraki birka hafta boyunca yalnzca ara sra grd. Sonra, yaklak bir ay sonra, Juanita bir gn hastaland. Yerine baka biri getirildi ve Juanita'nn masasnda bir not defter.

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