I had a really cool opportunity this afternoon. Not like bungee jump off the Cathedral of Learning in Pittsburgh cool, but still pretty one-of-a-kind. I don’t think the coolness of this opportunity hit me until I was finished. And since the outcome of this opportunity has generated much discussion and excitement, well, I wanted to share it with you!
Last Thursday, one of the Pulmonary Attendings and the Internal Medicine (IM) Chiefs approached our Medication Safety Coordinator about speaking at the monthly IM Patient Safety Conference. They were hoping to provide a multidisciplinary discussion related to the discharge process, with a focus specifically on medication safety. Our Medication Safety Coordinator was asked to provide an example of a Patient Safety Net (PSN) submission related to medication discharge errors and, possibly, led to a bad outcome. For those of you not familiar with PSNs, it is an anonymous reporting system of all errors, including near misses. It is a non-punitive system which allows all hospital employees and all patients to report an error (or potential error) through this web-based reporting system. Review of the PSNs allows various disciplines to identify potential areas of improvement within the system. Our Medication Safety Coordinator facilitates the review of medication-related PSNs through four Peer Review groups (Operations, Clinical, Cancer Care, and Outpatient). Last summer (2011), she noticed an increase in the numbers of submitted PSNs that were related to discharge medications. So while on her rotation in July (2011), I had the opportunity to analyze both the types of errors (i.e. med omission, med addition, wrong frequency, wrong duration, etc). and where the error occurred in the discharge process (i.e. transcription, IT systems, communication, etc.). We looked at the 77 discharge medication PSNs that were submitted over a five-month period (March to July 2011). The majority of the PSNs submitted were from the Outpatient Parenteral Antibiotic Therapy (OPAT) clinic and the Bone Marrow Transplant (BMT) clinic. These clinics have systems in place where person(s) review discharge orders/recommendations from the day before. When a discrepancy or an error is located in these ambulatory clinics, the discoverer voluntarily submits a PSN report.
My enthusiasm doesn’t have to do with the tangible analysis of discharge medication errors. Rather, it has to do with the opportunity to present our findings at the IM Patient Safety Conference. The Pulmonary Attending and one of the IM Chiefs started off with a vignette of a patient who was discharged without basal insulin and returned 2 days later with hyperglycemia. After working through a matrix and discussing the opportunities for intervention with the audience member, pharmacy had an opportunity to present. Our Medication Safety Coordinator presented the 10,000 foot view of the medication problems at discharge, and I presented our analysis findings. One of the Internal Medicine Attendings finished up the hour-long lecture with discharge programs that are in place across the country and what we (at KUH) are doing to tackle this problem.
Standing at the podium for our portion of the presentation, I scanned the audience members. Attending physicians… Nursing Directors... Medical residents… Pharmacists... Pharmacy clinical coordinators… VP of Performance Improvement… Infectious Diseases’ physicians… Pharmacy residents. Wow, what an audience to speak to!! The last ten minutes of the presentation allowed these audience members to share their thoughts, concerns and opinions regarding the entire discharge process. As the Pulmonary Attending stated, “Sometimes I feel like World Peace would be easier to achieve than a smooth, flawless discharge process.” But with all these different disciplines in the room – practitioners taken away from their silos and offering their expertise – we came up with some great ideas for the discharge process!
As I came back to the resident office and was discussing the whole presentation with my co-residents, one of them threw out the idea, “Hey, why can’t all IM Patient Safety Conferences be multidisciplinary? Can you imagine if Pharmacy had a standing appointment to present each month?”
Can you imagine? I can! While my opportunity was pretty cool, I sure hope this isn’t a once-in-a-lifetime experience.