Akhil Chhatre M.D., Tariq AlFarra, D.O., Adam Amir, D.O. and Abdul Halim, M.D. present at the Johns Hopkins Department of PM&R’s Grand Rounds on December 15, 2020.
All righty. Um So uh welcome everyone again to grand rounds. Um This is a special month we have had, this is our second grand rounds for December last week, we did our um research and clinical Expo keynote speaker, but we also wanted to um have a grand rounds this month focusing on uh patient safety and in this particular case, um we're calling it a Eminem or med and mortality. Um I wanna emphasize that we're discussing an actual case um that occurred in our PM and R department. And um so please remember that um H IP A um privacy uh is required when we talk about this. We've um tried to minimize any potential risk for violation, but there's always um you know, as, as we have more discussion, it's important to remember that and it's also important that we all think about this as a learning opportunity. Um We're not here to uh cast blame or criticize any individual or group's action, but to not uh an opportunity for us all to provide um safer and um better care to our patients and to work in a evidence based and um efficient way within the medical system. And hopefully, as we um move through the process of reviewing this case, we can think about that more critically. Um So with that, I believe our initial presenter is Doctor Tariq Al Farah. Is that right? Yes. So I will hand um the screen over to him so he can begin his presentation. Uh Tariq, do you have some give us slides presumably are you able to share? Yeah, I can, I can share my screen. Um Tracy just while this is uh Eric, while is uh pulling that up. I, I think again, um just to again, echo what, what Tracy was saying. But I think the other thing that I just wanted to add to that is that um we, you know, uh going through M and M um uh it is actually something that we're looking to improve upon itself sort of as a quality process. Um And so I think if, if folks have any kind of comments or, or think that there's opportunities for improvement, um You know, please send that my way. Um because um you know, we, we do want this to be uh you know, educational as, as as Tracy mentioned. Um And so uh just appreciate the feedback. So, um thanks again and I'll, I'll uh pass this off to thank you, Doctor Hoyer and uh just want to take a quick moment to thank everybody. Um Not only names listed on here but everybody who contributed to this uh including Doctor Hoyer and um many other um uh part of our department uh staff who we spoke to and got some valuable feedback. So, uh thank you everybody. We will be presenting today, um a morbidity and mortality case um that we uh like to refer to as a near miss case. Um And near Miss for, for what could have potentially been a wrong side case. We'll also be touching upon um a few other points and, and concerns um surrounding this case whether or not they actually occurred uh in this scenario. So for our particular case, we had a 51 year old female, she had a diagnosis of cervical spinal losis and lumbar, spinal losis evas like arthritis um of, of the neck and lower back. Um And she presented uh the day of the procedure to undergo um radio frequency ablation in her neck and lower back, which is basically um introducing um needlelike um uh uh inducers that, that kind of ablate the nerve or, or stop it from transmitting signaling um uh through later, later frequency waves. Um and she was to be getting these done on the left side uh both in the neck and the low back. So the way that uh we'll start off by um going through this case is, is talking about um the overall workflow and timeline of the day. Um And when I say of the day, I'm probably actually a little mistaken about that because this, this process, as we'll see in later slides actually starts even before the procedure day. Um, when the order is put in for the procedure, um, then the posting sheet is generated. Um, the order is transcribed, um, as it as it stands now. Um, and we'll talk about uh, what we're looking at in the future, but as it stands now, the order is transcribed, uh to the posting sheet uploaded to the patient's chart and then um electronically um put um onto the snap board and to the or schedule and we'll be touching more on, on uh where there's room for error there. And what, what we've done to address that uh in those multiple steps. Um There's obviously the personnel that the patient interacted with uh on the procedure day, the consenting process with patient patient teach back is very important to ensure that both the patient and the um uh providers are on the same page. Marking clearly is very important. Um in addition to the time out process. And so that adds several layers there um of, of checking and, and double checking and, and redundancy in that process, which uh is not necessarily a bad thing. So the way that we'll kind of go through um and, and divide this up um in an organized fashion is to address these four questions. This is actually a template that's commonly used for morbidity and mortality cases. And it asks what happened? Why did it happen? How do we reduce the risk of this happening again? And um how will we know that it is actually working uh whatever measure or intervention that we took? So, starting off with what happened? So pretty standard who was involved, we had nursing staff, pre-op and uh um attending fellow radiology tech and anesthesia personnel. Um what actions occurred kind of summarizing what we just saw in the timeline. Um So the case was posted in epic um consenting uh the patient arrived, uh consenting process occurred, there was the marking the time out. Um And uh that day particularly uh one thing that we wanted to point out was that there was actually training sessions occurring amongst all the team members. So nursing staff, um obviously, the attending always has their fellow with them. That's standard the radiology tech and uh anesthesia personnel each had a trainee with them that day. Um And we'll touch more on that later. Um So what we care members, uh care team members thinking and feeling um this kind of looks into how motivated are people, what, what do they see as benefits? Um What keeps them feeling um uh rewarded in, in partaking in the correct steps? And are there perceived pain points? Um And uh was each team member verifying the information that was received? Um And uh you know, were they considering and kind of alert to what was occurring? And I, I personally believe. And, you know, I think we're blessed to say that, you know, our staff in general, the people we work with. Um I have not encountered anybody that I felt like was just being outright negligent, not taking their job seriously. But at the end of the day, I think the whole, um although this may not particularly apply to us here, I think the whole thing that uh we took away from it personally was um human error can still happen. And the best way to um help to decrease that, that level of human error is to just have thoughtless uh processes in place to where um you know, even when people are distracted, even when people are um in the middle of something, having a bad day, whatever it is, they are doing these things every single time. Um And, and ensuring that that there's certain steps in the process that are not missed. Um So what happened in, in part two of this is what was the patient thinking and feeling? So did we confirm that the patient understood the procedure they were getting in this case? Yes. Um They were able to get consent from the patient. There was teach back. Um There was the marking that occurred um on the, on the uh correct side. Um However, what ended up happening was uh whenever the alcohol um prep was applied, um The marking was just close enough to the middle from my understanding that it made it a little bit tough to really look at it and decipher which side uh we were supposed to be on. And so at the end of the day when we talk about what, what happened and, uh we did kind of already touch here about what was happening at the same time. Um, you know, there was not an issue with staffing. Um, there was a pretty busy schedule that day For the most part, there was actually concomitant Tevis um going on as well, which that is an issue that has been addressed since. Um And then as we talked about earlier, the training. Um so, you know, when we look at what happened and ask ourselves that in this, in this case, you know, the main take home point was it really mostly came down to human error. Um It was a simple um instance where, you know, the, the marking look what the patient understood which side they were getting their procedure done. However, when uh the physician got to the table, um it was just a loss of thought that we were gonna go in on the right side instead of the left side. Um And therefore the focus moving forward from here is, is how uh why that, why that particularly happened and what what what we can do to mitigate that moving forward. Um So things that happened, that had a good outcome as we look back. So luckily this was a near miss rather than an actual wrong side incident. So the fellow actually identified that the needles were placed, um, on, on the right side instead of the left side, but they were introduced. Uh However, the actual ablation had not occurred at that time. So, right, when he realized that, um, he stopped, he notified the team, um, he, you know, the team huddled and they decided that since the procedure wasn't actually done on the other side, that it was just the needles that were introduced that they would proceed on the correct side. Doctor Shore informed the patient of the event. Um, the patient, um, was, was fully aware of what occurred and, and, um, was grateful that, uh, from reports that I heard, grateful that they informed, um, that they were informed of, of what occurred. And that luckily again, the, the risks of what had occurred were overall relatively minor compared to what could have been. Um, furthermore, in this particular case, it was lucky that the patient was actually scheduled to get the right side upl that next visit that they were coming back. But again, um, you know, we don't, I think we're lucky to have had a, um, case that was overall benign, but it's more about thinking what errors in the system, um, are there, what room and, and what gaps in the system do we have that we can fill? Um, so things that had a bad outcome So, although there was no harm uh done, um The procedure wasn't actually done on that side any time you introduce a needle to somebody, you're exposing them to typical risks of infection, bleeding bruising all that stuff. Um You know, obviously we want to uphold uh the confidence that our patients have in us, the trust that they have in us and any time you, you make a mistake, no matter how minor, um the risk of, of that uh being minimized is, is there. Um And uh, you know, the, the, if the patient had not been scheduled for both sides and this ad actually occurred, then they would have simply gotten a procedure on the wrong side without ever need it. And then there's all the risks that come with that procedure as well. Um So part two here talking about why did it happen. Um So the different areas that the rubric kind of addresses here for and, and addressing M and MS in general, I left these in even though some of these don't necessarily as we go through, apply to this scenario, but they are good things to think about and good things to consider as we reflect on our current process. Um So the task force was there a protocol to guide therapy? Um And yes, there was, they, we were able to, the team was able to have a huddle. Um, they were able to, um, decide that based on, um, the amount of exposure that Beijing had had to the procedure which was minimal that they could proceed with the contralateral side uh provider factors. Um So they always asked was, um and in this case, uh we're all gonna be tired, all gonna be. Um And uh it's reemphasizing how important it is for us to um have systems in place that are tired, proof that are overloaded, proof, even burnout proof in some cases, uh that we are going to be manually going through these checks and balances every time. Of course, that day, you know, there was the training going on, there was Thomas and visits. I don't wanna reiterate that too many times. Um But, but um other caregiver factors related to the deficit. Um and we kind of already talked up on that as well. Um So moving forward, you know, and asking ourselves, did we really engage all members of the team in the time out process? Did we take a step back? Did we have everybody confirm which side we were gonna be on? Did we have everybody say verbally? Yes, they agree. They verbalize what um what procedure was going to be done that day. And ever since this has occurred at, you know, in the times that I have worked um in the procedure rooms, it, it's been refreshing to see how, uh much more of an emphasis there are on redundant laterality checks on making sure every member of the team everybody standing in the room um has looked at the consent, has looked at the orders and has confirmed that they agree um and verbalizes what they're agreeing with um knowledge and skill factors. Um So again, I don't think anybody found the protocol confusing. It's just perhaps that the protocol was not stringent enough to keep uh from, from these gaps um occurring um and the technolog factors. Um although in this case, you know, everything was submitted correctly through the system and, and through epic and things of that nature as we'll touch upon later, that is another area where there has been room for error and, and error has occurred um as to posting those cases. Um And as far as I'm aware, luckily, um it never actually carried out to resulting in a procedure that actually occurred on the wrong side. But the fact that you're still posting these cases, um in epic in the system, they're being transcribed incorrectly or even just ordered incorrectly to start with, um is definitely something that we're going to be touching upon when talking about local environment. So again, on this day, the equipment and everything was functioning properly. Um And uh you know, one thing that doctor Shocker did note that day was, you know, perhaps, um he was less attentive to what was going on in there just because he had a call from a patient. Um and he stepped away from, from the bedside for a moment. Um As the fellow was continuing with the procedure, um institutional factors, uh there was adequate personnel again during training. Um And one other thing that, that, you know, we touched upon was we expand this out to think about the culture as well. So are there aspects of your patient safety culture that promote doing the wrong thing or engaging in risky work around? And although we're lucky to say, you know, at least here it happens, I've not witnessed that there's anything that promotes this or pressures people into doing the wrong thing. Um Actually, it might be kind of the opposite problem. I think we all have a very collegial uh culture, we get along very well and I think sometimes it, it can be hard just from human nature to balance friendship with someone who really is your professional calling, you develop a sense of trust. Um And sometimes that sense of trust um can go maybe a little too far where we stop checking on each other and um confirming that, you know, human error, um None of us are immune to that. Um Nonetheless, also, you know, somebody who I can imagine in a different work environment um is close to somebody on a personal level, might find it awkward to have to check things or do whatever. Um And we need to find ways to, to make sure that these are not factors uh moving forward. So I will uh let my colleagues uh take it from here. Um You guys wanna go ahead. OK. So, um I know we, we talked about this case and the reason why we highlighted that, that particular case that uh Tarik just went through was because, you know, a even though it was a near miss case, it's a very good learning opportunity. Um you know, no meds were given a procedure wasn't actually started. But, you know, there have been times where, um you know, when you, when you think about a procedure like this, you can think about how much it has uh such a great potential for patient harm. Um But we wanted to bring to light other uh incidents that have to do with um incorrect posting, especially of laterality or of, of the site itself. Um So there have been efforts to address this, which we'll talk about a little later. Um But unlike the previous case, which you can also, you know, um kind of can attribute to some human error, there's some human error here, but we want to look at this from more of a system standpoint um to see what we can do differently, especially when it comes to actually posting these procedures. And I think if we can actually kind of analyze what's going on at the origin of when these orders are being placed, uh we might have a better um idea and understanding on how to prevent a lot of these errors. So the two cases that in particular, these two heroes that, um going over. So the first one back in July, there's one where, uh, it was posted as a right sided procedure in Epic. Um, but per the, or posting sheet and for the patient, it was supposed to be left sided. Um, so luckily they, they were able to catch that even though it was posted in Epic as right side. Um And then in August, this was more of, you know, the site which can also be very, you know, it's probably even more dangerous, most likely um posting. She said the procedure was on the right arm and then when the patient was asked, it was actually on the right hip. Um and this was later verified by Doctor Chatri as well. And huddle was performed prior to this procedure and uh procedure was done successfully thereafter. Um So now reading through these cases, we ask ourselves now, um you know, how can these prevent, you know, this be prevented? How can this miscommunication or um just a lack of consistency between the or sheet or epic? How can we avoid that and how can we reconcile it so that it's all the same? Um So when we talk about the interventions on the next slide, um you can get on the next slide, please. Oh, sorry things. Um Yeah. So one of the things, the big goals that uh that has been placed is to try to plan, um, and, and devise an epic order set, um, that can replace these email in basket orders, um, which can, can kind of get lost, especially in translation. And the issue with a lot of it is, uh, there's so much manual transcription involved with email in basket orders. Um And so the whole point is to do something that's trackable, that's standardized, um, where everything is kind of populated already. Um, and it's, it's kind of like a multi stepp workflow for the physician to fill out. Um And I, and that's something that's in the works. There have been some order sets that have come out um that still need tweaking, that still need editing. Um But that's one of the biggest goals in terms of trying to avoid these errors. Um Another thing that's actually being done is uh reducing the frequency of same day, next day add-ons. Um So they, there's an agreed upon cut-off time. Um The cut-off time uh I believe is about uh 48 hours prior to uh the block date time. Um And so that's something that has been implemented already. Um And then another intervention that uh that that has been in place is uh just developing a new line of communication between the PM and R uh group as well as the Acute Surgical Center staff and uh and how to request to add more patients. And I think this is very important because, you know, at the A sc there's a lot of different procedures going on. There's a lot of different requirements for them. Different time limits, different types of anesthesia, different types of um specialists. So all of these things need to be hashed out. And I think the new line of communication will help kind of schedule these patients in a safer manner and provide adequate time for uh properly consenting and marking and doing all these uh basic um steps that we do during procedures. And then on the next slide, going back to a lot of the factors that um Tarik kind of mentioned uh kind of breaking it down in a way to um get a sense of, of what really happened that day and how rare some of these events actually are and even if they are rare there, they are still factors that we need to be cognizant of. Um So obviously, uh uh one of the major reasons why this er particular error could have occurred, um It's, it's very rare to have every member of the team have a trainee. Um It doesn't happen that often, but uh it's something that we always have to look into and it's something that we can think and maybe try to prioritize who is training on what day and kind of schedule in a way where there isn't too much training going on. Um And then the lack of, you know, redundant laterality checks and confirmation that could be another reason as well, but it happens very rarely because we have such set protocols in place. Um Other major reasons that are more often uh the reason why such type of errors can occur. Um Obviously, we talked about concomitant workflow, whether it's talking to a patient on a phone, whether it's, you know, having to talk to the last patient who had the prior procedure, um Other things going on as well, all of it um can contribute to just kind of missing things like this. Um And then trust team members, uh Tarik touch base touched on, you know, uh kind of, you know, where we have a culture where we're so friendly with one another. Uh We might end up trusting our team members a little too much. And I think it's our responsibility, not just as, you know, in health care, but just in general for patient safety to make sure that uh we, we're at least looking out to see that our colleagues are doing their jobs and they're doing them correctly as well. Um And then in some of the minor issues which are rare but are obviously present, especially in the health care system is human error, which is involved in almost every defect. Every um every error that you can think of human error is always a consideration and provider fatigue is one contribution to that. We do our very best to minimize that with wellness and uh trying to limit hours and trying to make sure that all of our providers and staff have adequate time to recover and things like that. But um, there will always be fatigue when it comes to work itself. Um And then uh in terms of things that happen often, so site marking, it's obviously removed during the prepping process. Uh especially when, um, even if you have something that's a mark large or small, that's something that or even when you have to cover the patient up during the draping process, that's also another issue where you kind of miss the marking and then a false sense of security. So I like to differentiate this between trusting team members in the sense that with the false sense of security, it's the idea that, you know, you feel secure that you're in a system that if you don't catch something, someone else will. So it's more of having a self awareness that you need to be cognizant of everything going on and doing instead of looking and instead of looking also at people doing their jobs, you have to always ensure that you're doing yours as well. Um And then the next uh slide, we go through some of the intervention and how strong we think they actually are. Uh So, you know, obviously, if you just tell a team member, oh, we almost this was a near miss. Let's not do this again. Let's remember this moment that, you know, that's something that kind of sticks in for a day or two, but that doesn't really help anything. Uh, doing a two person verification can always lead to more errors because again, you can just trust the other person and say, yep, that's the side that we're doing. Uh, marking a bigger is also not too helpful. Um, just because at the end of the day it gets wiped off. Um, but other things that we can do, you know, there have been talks of more um you know, stronger type of intervention. So maybe implementing a physician let time out. Now, I know a lot of institutions have different um protocols for this. I think historically here, the uh it's the nurse who actually leads the time out. So um it really depends from institution, institution, how that's done. Um And then obviously limit the number of trainees, which I think was a big part of this uh particular near miss and then uh mark, sometimes marking positions, initials is also another thing that um does help, but again, that gets wiped off as well. Um And then more stronger intervention. So to have a consistent standardized protocol with redundancies is very important with all team members. So I know doctor Chatri actually brought this up with us that he has this um like ask protocol. So ascertain knowledge. And so he, what he does is before putting any needles in, he points at every member of the team um during the procedure and confirms laterality with them. And um that's one of the best ways I, I believe that um that's one thing that he added to his work flow as a result. Um Another thing that uh that I brought up earlier is this epic order set as well. I think the redundancy and the epic order set would also contribute to uh a stronger intervention. Uh And then I think seizing concomitant activities would be uh a very strong uh intervention just because, you know, if you're focused on that case, you're, you're away from phone calls, you're away from other things that, you know, and this is not just for the provider, this is for nursing, this is for um uh the radiology tech anesthesia. And I understand that there are, uh you know, everyone needs to learn, everyone needs to train. But I think if we limit that, especially during procedures like this to maybe one team member having a trainee or something like that or two members having a trainee, then it would most likely would work much better. Um And then marking large initials. But the, the, the big part about this one is trying to develop or use something that's not gonna get uh erased easily in the prepping process, uh something more permanent, even if it has to be there for a couple of days. Uh I think would be very beneficial and I think most patients would understand the use of it All right. So, moving forward to, um, just in an effort to limit um, these near misses or incidents from happening, um, in the, in the future or, or perhaps even, um, eliminate them altogether. Uh, we did, uh, do a literature review to help us, um, understand, um, have an idea of what other surgical centers are across the country are, are how are they handling their, their sign in and time out procedures? Um Just wanted to share this um surgical safety checklist that was created by the who and it has been widely adopted by many surgical centers around around the world. So it's a, it's a three part um checklist. And uh the first part is the sign in that's mostly getting the patient um demographics checking for an allergies for, for uh medication lists. And that's done bef before, before the induction of anesthesia. And then the, the time out um part is done before the, the skin incision and like Abdullah saying this, this part is uh usually uh historically, has been led by, by uh the nurse, nurse manager and, and the uh surgical suite. And then the, the third part is the sign out part that's uh done before patient leaves the operating room. Um So the, however, the caveat with this checklist is that it's by no means a comprehensive and a um one it's, it's actually a, a generic check checklist and the who uh advised not to use it as a sole uh safety measure uh for for surgeries. Um as you can imagine that doing an epidural injection or an R FA procedure uh can have less likely um uh less chances of, of having errors happening at the, at the sign out part, comparing it to doing um an open cardiac surgery, for example, uh with having more uh fine in instruments and uh surgical gus and, and such. Um so based on and, and the literature review, actually, it was evident by um um uh the centers that used this as a sole uh measure, had more incidents and errors occurred. Uh comparing that two centers that added a supplemental checklist, uh that is more specific to the, the specialty and, and the practice. Uh so it's kind of a two layer two la layer of safety safety net before, before induction of anesthesia and uh and um and uh skin incision. So based on, on uh on that few changes were went into effect immediately um and involved all team members and the surgical suite. Um And so from a resident and fellow standpoint, we initiated a long longitudinal uh quality improvement project that is a one year project. It's led by uh Doctor Chad and we started that um December 9th and we will be collecting data from uh Doctor Chad um on uh time points and there and then two months, six months and 12 months, uh time point to collect data about uh numbers of incidents and, and compare it uh to uh that prior to implementing the changes. Also, nursing and radiology techs will, will be doing their own separate checklists um and then cross cross matching it uh with the other team members. Um And I understand that this is uh probably going to be more heavily um invested into catching errors at the sign end and uh perhaps the time out uh part. Um and that's, and that's fine because um and given the nature of doctor uh chad uh procedures, we're expecting less errors to occur at the sign out, uh sign out part of the uh of the uh checklist. And this will be compared on weekly basis uh for the following week. Uh the patients that are scheduled for the procedures the following week. And uh since this near mess um involved a wrong side. Um so the major change that has been implemented was a physician led time out um and laterality check. And uh I know Tara and Abdul might have touched on this. Uh um And so what will happen uh from here on is that the attending will be required to uh to uh check the side of the procedure done and actually uh check it against all the other team members to make sure that it's matching uh prior to uh an induction of anesthesia and, and, and uh uh needle insertion. Um and this uh will be uh objectively measured in the Q I project, um, in 26 and 12 months, uh, from September 9th. And it's, um, it's done, uh, by residents led by attending. And so far we were, uh, we passed the two month mark, uh, uh, November 9th and we did the check in with Doctor Chad and there was, uh, uh, zero incidents and, and zero their message. So that's, that's a great sign and we will, uh, be providing a uh a Q I project report at the end of the year. So with that, um I'd like to open it up for any questions you may have. This is Julie. Um I have um just a suggestion that the team review the um safety quality procedures for pre op check and site marking um because they have a very similar to what similar table to what you showed with who and it um says that an X is not sufficient, you know, it really needs to be a single use pin and it needs to be initials of the provider. So I think we just need to be compliant with hospital procedure with whatever Q I um studies we're implementing. Yeah, Julie, I think you bring up a an excellent point. Um I haven't actually seen um the document referring to myself, but um I think um it, it would definitely be good to look at and compare one thing that I will say as at least as far as the marking is going is that we still doctor shot, obviously, is still using his initials. He's just making them a lot bigger. And the goal behind that is because the markers that we just have available to us, although it would be ideal to get more permanent markers or, or, you know, things that might stay on and, and um, not be rubbed off by the alcohol prep. Um He has made them a lot bigger, um, in order to hopefully get a little bit of that a, that, that is further away from, from the, uh, operational field. Um, so that it's not smeared as bad. But yeah, certainly a good point and definitely something to consider, uh, for the Q I project as well. I can send the link to, um, at least the chiefs to get it, you know, to you guys so that you can look at it. I just haven't heard anything about the pen in any sort of safety huddles that, that's an issue. And you think if it was something that widespread, it does say in the policy it has to be hospital approved. So I'm wondering if maybe we're using something that isn't official. I would hope the A sc had that. But you never know. And, um, because, you know, with how much is going on everywhere that if this was really an issue and there's preps that are obviously gonna be a lot more involved in cleaning the site than maybe what's happening, I'm thinking that maybe our pens aren't, what is official. I don't know. I'll let you, I'll let you guys look at it once I send this, I also suggest in my limited, relatively limited experience. Um, the, I have tended to see these pens at every institution I've trained at so far. Same types of pens for surgical, for procedural use. They, I've never seen a pen that withstands the alcohol prep. So it is a good question. Certainly be curious to, to figure that out as well. Um Yeah, this is, this is, er, um you know, first of all guys, I just, I just wanted to commend you guys. I think you guys did a really outstanding job on this presentation. I think you went into a lot of detail and depth and it's really nice to see sort of the efforts that you guys are taking. So, II I definitely wanted to recognize that. Um just, just a couple quick, quick questions. Um Now you, you mentioned about doctor shot, we, we do have other pain physicians and the department is looking, you know, potentially in the future to expand and things like that. And I just wanted to get your thoughts. I don't know if that was discussed with other um providers. I um that was one question. Then the second question I just uh was curious about was in terms of the Q I project, in terms of monitoring, you mentioned some procedures that are taking place, like, for example, the physician let time out is, is that being sort of observed and then, or is this more sort of anecdotal, like, uh, you know, you sort of touching base with doctor and asking him if, if, if issues happen. I'm, I'm just wondering sort of how objective some of this data is being collected. Yeah, absolutely. So, our main contact was with Doctor Chad and, um and that's uh uh the, the change that has been also implemented was was enforced by, by him. Um And uh as, as I understand, there's a, a follow as well um in there who will uh also participate in, in uh in the Q I project. Um And in terms of um the changes, uh we actually did not have um observed them done on the, on the floors. Um And it was uh something that uh Doctor Chad mentioned that it was uh uh consistently implemented um right after this incident happened. And uh and we are the objective part about this is touching pace with him and um and comparing the, the cases before um or the errors that happened before uh to the ones moving forward and it's gonna be a, a longitudinal one year um um effort that uh collects that those data. But in terms of monitoring, um we, we do not have that part as of yet. OK, thank you. Yes. Hey, um I do have one question, Adam uh Tarik and Abdul, I'm not sure if you guys have the answer to this. Um or if you guys talked about it when you guys discussed it with doctor. But um regarding the scheduling of the procedures, I know certain, like I know for example, like other departments, they actually have like an order set an epic. Is there a reason why we don't have one on our end for our department or it's just like? Yeah, I guess that's, that's the question. That is a really for that, please, please, please. Uh hi, this is Laurie. I'm getting a lot of feedback. Sorry, sorry about that. Yeah, I did. I had two speakers go and pardon me? Um So there is an order set that has been developed and one of the providers is currently using the order set and has identified some um some things that need to be edited in the order set if you will and that is being worked on. Now. Um We are planning to roll this order set out after the first of the year for um the remaining pain providers as well. So that will go a long way in reducing um reducing, eliminating these um some of these near misses and, and um errors, the order set will populate the posting sheet. So that will result in um no further transcription uh needed to be done. It will populate the case in snap board. So it will reduce um some of that transcription as well. Uh and, and should make the process a little bit uh smoother for this uh posting staff. Ok, cool. Thank you. Mhm. Ok. This is Julie again. Sorry everybody, I just wanted to add that. I really appreciate the work on this. I didn't know if anyone had informed you, but this was chosen for the department's M DNA. So that's something we share hospital wide um November and also in May. So we put it on our safer matrix which really kind of quantifies the seriousness of and um kind of safety events trends in the department as well as how widespread it is. So we wanted to list that and it will be great and made to be able to um share some of the progress that's been made for this. Um It gets institution um visibility as well as being compiled with other um for matrix items across the institution and it gets tracked, shared also with the board. So it's really important and the work is great. Thank you so much Julie. I certainly I didn't personally know that, but um it's very exciting to hear and uh I'm sure I speak for all of us when I say we'll be happy to help out with that. Any, any way that we can. It's very exciting. Um Yeah, if, if II I didn't wanna, sorry, I know I Julie and I have been sort of speaking a lot this is Eric again, um, I think the one, you know, the, maybe the one thing that, you know, that this, this sort of, this issue does to touch a little bit up, uh, upon though that I, I did, I did just want to raise because I think it's relevant is that, um, you know, when, in terms of, in terms of when mistakes do happen, um, I, I think, I think it's important that also, again, you know, from an educational standpoint, um at least what I'm aware in terms of the literature is that oftentimes practitioners attendings and residents and all that, they feel like, um that, you know, if, if we do make a mistake or an error that uh you know, that we feel like there's gonna be some bad consequence that happens. And so as a result, what often happens is that uh you know, things aren't sort of reported. Um And, and I guess at, at least uh for the trainees in particular, um you know, just, just to, just to reinforce that, that actually, um at least, you know, and again, this is this issue actually has been studied and, and, and, and, you know, going to patients and, and actually apologizing and telling them they're sorry and, and sort of explaining actually, uh goes a long way in terms of mitigating sort of long term outcomes from, from these negative consequences. And I, um I think that's important to keep in mind and then the other thing is, you know, 11 of the nice things about being at an institution like Johns Hopkins is that there is sort of an infrastructure of how to deal with this. We do have uh a legal team uh in terms of risk management as, as well as, you know, our department leadership and all that. So if, if events do happen, you know, if and if the residents in particular or fellows and so and so forth are involved in events where there's an error that takes place. II, I do want you to feel like this is, you know, something that you guys can, can bring up to, to our leadership and, and that, um you know, ee again, even if it was, you know, uh you know, harm and things like that, that it's, it's, it's better to, to make it known than, than to, to try to hide that. There's, it's usually we can kind of deal with that uh more proactively and, and this sort of the kind of the messier side of medicine that I think we don't often like to talk about but is, you know, unfortunately, reality. And so as you guys highlighted this case, fortunately didn't lead to a, a really a serious event, but it could be and, and, but I think it's important that, um you know, just, just to mention again, these, when, when, when accidents do happen, uh it's important that we're addressing that in, in the right way too. And I just wanted to mention that Eric, thank you for that. I wanted to thank the residents. You guys did a tremendous job. This looks really well thought out well put together and, and happy to help contribute. Um But touching on what you said, Eric and Julie, you know, I was just doing my risk management um module for that. They make us do every two years for Hopkins and they talked a little bit about um you know, if events were to happen, can you? Um because I don't think most people may or may not know that there is an act, there's actually a process by which we are to um either document or not document or report or, you know, there's a way that we are supposed to do things at our institution. Can you speak a little bit about that? Um Because uh you know, there is some language about, you know, what is discoverable in the state of Maryland versus not. And I'm not saying, you know, anything to do with your misses. I'm talking about in any aspect of our practice. So, I mean, I can tell you so and so so in terms of the exact language for documentation, when when these sort of events have happened, my usually my first step is actually to contact our risk management office and to discuss that with them and uh you know, explain sort of a situation to, to figure that out and that, that's been my first line. Um I, I'm not sure in terms of the um the recommendation in terms of, as you mentioned, in terms of documentation and, and, and so forth. If anybody else has uh a more precise answer, I, I'm, I'm happy to, I, I'd, I'd be interested to know that as well, but I, but I do usually in these kind of situations, do try to uh you know, um would would want to make the institution uh a aware um like I mentioned, particularly in the risk management group. Can anyone hear me? We can hear you now, Tracy. Um So, um does anyone else have any other comments or questions related to this case? All right, I, I wanna reiterate. Thank you um Tarik or Doctor Al Farra, Doctor Halim, uh and doctor Amir for um preparing and very thoroughly thinking through this case. Um and the um best practices to ensure that uh improvement of care and patient safety moving forward. You guys did a really wonderful job and I really appreciate everyone's um participation and conversation. This is a um important component of improving the culture of our department that we can be open and communicate about um uh medical errors and, and mistakes and ensure that we do a better job um for our patients. So um we can wrap up today's uh grand rounds. Everybody have a wonderful holiday season and Um Yeah, doctor sick. Go ahead before you miss everyone. I um I'm just piggy bagging on your last comment. Basically, Tracy, I think this is very, very important that we do these M and MS. Um And I appreciate the broad attendance uh today. Um So it is uh very important that we learn from our uh errors or near errors or uh uh and the only way that we can be a learning organization is we address them, we should not hide them, so we need to bring them up, we need to discuss them. There is a uh as you as the residents have shown today here. Uh There is a some formal process by which we can review this uh in, in, in a professional way and that becomes like a, a learning opportunity as Tracy mentioned at the beginning. So uh it is my hope and intent that this will continue and repeat in some regular frequencies. We, I know we discussed it with Tracy and Eric and others. Uh The idea of uh ongoing M and MS so will be uh identifying this and, and uh uh from, from different aspects of our department so we can discuss them all together and, and all learn from these situations. So with that, thank you. Sorry, tries to interrupt and then you can wrap up the the salutations. Yes. No, no, please. Um And thank you for um chiming in doctor sick. So um yeah, everybody have a wonderful holiday season and um, it's almost 2020 so 2020 20 is almost over. I should say so. All right, take care. Thanks, everyone and thanks for time. Wonderful, good job. Happy holidays. Bye bye, bye, bye. All right. Bye. Bye bye. Good job.
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