February 21, 2003

Preventing malpractice is priority at VUMC

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Kelley Work with Environmental Health and Safety helps a patient through the decontamination showers during a bioterrorism drill at Vanderbilt. (photo by Dana Johnson)

Preventing malpractice is priority at VUMC

The title of his talk was surgical malpractice, but Dr. John A. Morris Jr., professor of Surgery and director of the Division of Trauma, spent most of his time last Friday talking about ways to improve patient safety and care.

“In the next three or four years, we’ll profoundly redesign the way we deliver care at the bedside, at least in the high-intensity setting,” Morris said during Quality Grand Rounds.

“We’re going to get nurses back to the bedside,” he said. “We’re going to change the nurse from a recorder of information to an analyzer of information, and ultimately the bedside nurse is going to be the person responsible for protecting the patient.”

Morris, who founded the Division of Trauma, has been analyzing systems of patient care for several years. An analysis of “adverse events” that occurred in three of Vanderbilt’s surgical patient care centers during the late 1990s revealed some unexpected findings, he said.

In particular, the failure to “manage” the expectations of patients and their family members, and communication failures between caregivers were found to be the most common contributors to adverse events, including instances that resulted in malpractice cases, he said.

“In the ICU environment, the failures are multiple and they occur at the interface of complex systems and disciplines,” Morris said. “They occur between one service and another service, between the pharmacy and the bedside, between radiology and the attending physician … It became clear to me that we needed to do some things at the bedside to be able to make the environment safer and also to handle risk better.”

Of the three surgical centers he analyzed, Morris said trauma was most likely to result in settlement payments for malpractice claims, even though its rate of adverse events was not significantly different than that of cardio-thoracic surgery, for example.

Cardio-thoracic surgery often is elective, whereas trauma patients and their families seldom are able to choose the therapy that is given or prepare for the possible outcome of treatment, Morris noted. In addition, they often experience anger about the incident that put them or their loved one into the hospital, “and that anger is often transposed to the caregiver,” he said.

In an attempt to help families understand better the care patients receive and just how sick they are, the trauma unit extended its visiting hours to 20 hours a day. “The nurses hated it,” Morris said. “The doctors hated it. It is tremendously inefficient.

“It was an absolute disaster, except when we looked at the outcome,” he said. Over a two-year period, complaints about care in the trauma unit dropped by more than half, below the average for Vanderbilt hospital units.

Patient complaints are strongly correlated with malpractice risk, according to a team of Vanderbilt researchers led by Dr. Gerald B. Hickson, professor and vice chair of Pediatrics. This correlation “offers an excellent opportunity for addressing sources of patient dissatisfaction that can lead inappropriately toward the courtroom,” the researchers reported last June in The Journal of the American Medical Association.

The medical center must do more than try to “manage” its risk of risk of being sued, Morris argued. It has got to create a “culture of safety,” he said. “We need to capture errors and analyze those errors. On the basis of that analysis, we need to redesign our systems,” and identify and intervene with health professionals who are practicing in an unsafe manner.

“We’re working on that culture, but we’re not there yet,” Morris continued. “There needs to be clear accountability of who is responsible for implementing safety initiatives, and auditing that accountability.”

Several safety initiatives are under way.

To reduce the potential for human error due to fatigue, “we’ve now put in for the house staff an 80-hour week and we are pretty close to doing that,” he said. In addition, “we have mandated for the faculty one week out of seven. The eighth week you will rest. You will not take any clinical responsibilities, and we prefer you to be outside of the hospital completely.”

In the trauma unit, Morris and his staff have adopted a standardized approach to training similar to that used by industry and the military. Nurses and doctors are trained as a team to do specific jobs in specific locations, and patients are “aggregated” in one place.

“We are evaluating something called ATOM, which is an advanced trauma operative management module,” he said. “We have started the first step of bringing (in) scrub techs, attending surgeons, fellows and residents … and simulating disastrous scenarios in the operating room so that we can get the steps of the process down.

“Ultimately you get certified to be able to take care of the level 1 trauma patient in the emergency department or to be able to do a level 1 trauma case in the operating room, or you get certified to be taking care of the sickest patients in the ICU,” Morris continued. “We’re not there yet, but we’re walking that path.”

Job descriptions of physicians, pharmacists and nurses also are being changed. “We’re going to move them closer so that ultimately those descriptions overlap, so that there is redundancy, so that more than one person is responsible for picking up a potential adverse event and acting upon it before it becomes an adverse event,” he said.

In the Emergency Department, nurses have been given “White Boards,” electronic devices that continuously update their patients’ medical status and treatment. The nurses are responsible for analyzing that information and responding quickly if, for example, the patient’s magnesium level drops.

In addition to the White Board, bedside nurses will get information from Star Panel, an electronic method of viewing and interacting with a patient’s medical record, from telemedicine, from WizOrder, an electronic order entry system, from the lab and from the pharmacy, Morris said.

“I find this very exciting,” Morris said. “We’ve got an opportunity to bring together an experienced management team, physician extenders and telemedicine to dramatically redesign care at the bedside.”