Error-proofing your office: Rules and protocols to help reduce risk

Patient safety experts tell primary care physicians to simplify, systematize and, for goodness sake, wash your hands.

By Andis Robeznieks — Posted Jan. 12, 2004

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Everyone is familiar with the sight of politicians in their "power suits" and hard hats touring a construction zone.

No one expects these officials to start riveting steel girders together, but safety rules dictate that everyone in the area must wear hard hats, so they do -- even politicians who just had their hair coiffed for the television cameras.

Physicians, nurses and patients don't have to worry about tools or heavy objects falling on them from above, but many experts believe everyone would be safer if uniform no-exception safety rules also were instituted at doctors' offices.

"Patient safety crosses the spectrum from people falling when they get off an exam table, to prescribing errors, to things as basic as hand washing," said Daniel Stryer, MD, director of the U.S. Agency for Healthcare Research and Quality's Center for Quality Improvement and Safety. "Some of this is not rocket science; in some ways, it's harder."

Ever since the Institute of Medicine's 1999 report "To Err is Human" was released, patient safety has become a frequently discussed aspect of health care. Nevertheless, with its focus on hospital-centered topics such as wrong-site surgeries and nurse-staffing ratios, some primary care physicians easily tune out the subject.

This is changing, however, and even hospital-focused organizations such as the Leapfrog Group are starting to get involved with improving safety in the doctors' office.

Research is being done and theories are being put forth, but -- according to Nancy C. Elder, MD, an associate professor of family medicine at the University of Cincinnati College of Medicine -- these theories have yet to be put to the test.

"It's problematic to say, 'Do this and you won't have errors,' because no one knows for sure yet," Dr. Elder said. "There's absolutely no evidence yet to support anyone's claims, so it's still totally anecdotal, which is kind of the problem."

But what the primary care patient safety movement lacks in hard, scientifically proven, evidence-based universal truths, it makes up for with good old-fashioned common sense.

"When there are standardized protocols followed within a practice, there seems to be fewer errors," she said. "Errors tend to occur when, within a practice, Dr. Jones does it this way with his nurse and Dr. Smith does it that way with her nurse."

A subset of quality

Robert Gillette, MD, a "semi-retired" family physician, author and instructor at the Northeastern Ohio Universities College of Medicine in Rootstown, has his own theories on patient safety.

"Conceptually, in a doctor's office setting, patient safety is a subset of quality, which is doing whatever you can so the patient has the best possible outcome," he said. "Part of a successful patient safety plan is simplifying all the issues physicians face from day to day, so they can focus on it without being overwhelmed by everything else."

The word in vogue for doing what Dr. Gillette suggests is "system," and physicians are constantly being told to systematize their practices. But what does that mean?

"It's a large term," Dr. Elder said. "Basically, it's the people who do the work and the tasks they have to do and how and when they do them, the equipment they have to use, and the hierarchal structure under which they operate."

Bruce Bagley, MD, the American Academy of Family Physicians' medical director of quality improvement, said the key to a good system is reducing reliance on memory.

"You can't do it by the seat of your pants anymore; it's too complex and there are too many things to keep track of," he said. "Developing systems [doesn't] always have to cost a lot of money, but they usually take effort."

In addition to systematizing, physicians often are told to adopt a "culture of safety." For Dr. Stryer, this revolves around one of medicine's oldest principles and is the first step in making an office safer. "It's having all the members of the practice -- physicians, nurses, support staff and patients -- keeping in mind, above all, to do no harm."

Combining systems and a culture of safety also means having emergency plans in place and making sure everyone in the office knows what they are, Dr. Stryer said.

"Every office needs to be prepared for certain occurrences: What do you do in case of a fire? What do you do in case of a patient who's out of control?" he said. "Offices have to have standard operating procedures in place to make it a safer environment."

In physical terms, a culture of safety can be seen in a sidewalk free of snow, a "Caution, Wet Floor" sign on rainy days, hallways free of clutter, electrical cords tucked away, railings where needed and no tables on wheels in places where patients may try to use them to help themselves up from a chair or down from an exam table.

"Because everyone knows falls are a possibility, people seem to be more aware and take precautions," Dr. Elder said.

Less-obvious precautions include using equipment designed to reduce the risk of staff being pricked by needles, having boxes of surgical gloves in convenient locations and having sinks available so physicians and staff can wash their hands when needed without having to leave the exam room.

Dr. Stryer also suggested that everyone on the staff receive a flu vaccination. "Although it sounds so incredibly basic, it's something we're not doing enough of."

Cause and effect

At an AHRQ conference on patient safety and ambulatory care, John Hickner, MD, director of the AAFP's National Network for Family Practice and Primary Care Research, presented findings of a study that looked at "patient safety event" reports filed by doctors, staff and patients.

Common problems were incomplete or unavailable charts, lab test and x-ray mix-ups, and errors relating to medications, filing and diagnostic imaging. There also were "knowledge and skills errors" that produced the incorrect execution of clinical and administrative tasks, wrong diagnosis and wrong treatment decisions.

Consequences included putting patients at risk, delays in patients receiving care or starting treatment, suboptimal care, making patients upset or anxious, and wasting the time of doctors, staff and patients.

Electronic medical records and computerized physician order entry for prescriptions are seen as possible solutions, but Drs. Bagley and Elder warn against viewing them as a silver bullet to solve all problems.

"Computers have a definite place, but it's not going to be the entire answer," Dr. Elder said, adding that if a computer system is installed, time and resources have to be set aside so staff can learn how to use it properly.

Dr. Bagley said he thinks that, if used correctly, electronic systems can help eliminate the most common causes of medication errors.

"Clearly, I think the No. 1 reason for outpatient medication errors is handwriting," he said, followed by prescribing drugs to which the patient is allergic and prescribing something that produces a negative interaction with other drugs the patient is taking.

A good EMR system will automatically check for allergies and possible drug interactions, Dr. Bagley said, adding that "the next step is checking dosage compared to patient weight and kidney function."

Dr. Stryer said EMR systems should send reminders and suggestions such as "Should this patient be on beta blockers?" or "Should this patient be on an anti-coagulant?"

"These systems can be extraordinarily helpful," he said.

For maximum helpfulness, Dr. Gillette said these systems need to be automatic and not rely on physicians to initiate the processes needed to mine records for useful information.

"If there's a take-home message, it's the idea that, in order to be effective, they have to be as self-operating as possible," he said.

Dr. Elder said electronic systems also can be set up to have "forcing" functions that can eliminate errors of omission by not accepting forms unless they are completely filled out.

"With paper forms, you can leave a lot out," she said. "But good IT programs make you fill in all the blanks, and that tends to prevent some of those clerical types of mistakes."

One important factor that's sometimes overlooked with implementing electronic systems is finding a place to keep the hardware.

"If a practice commits to computerized records, to make that work, there has to be room in the exam room for a terminal," said Dr. Stryer, who added that his wife works in a practice where she has to leave the room to enter patient data into the record.

Fax machines also can be problematic and a source of drug errors.

The Institute for Safe Medication Practices reported how 800 mg was changed to 300 after the left side of the "8" was sliced off, how "fax noise" such as streaks and random marks changed a 40 mg prescription to 10 mg, and how 12.5 mg became 25 mg as a gap in the fax took off the "1" and the pharmacist misinterpreted the decimal point as a random mark.

The ISMP suggests physicians give a copy of the prescription to patients so they can present it to the pharmacist for verification against the fax copy. It also suggests replacing fax machines when quality becomes a problem.

Technology helps, but remember to talk

As health care looks more to technology to improve safety, Dr. Stryer reminded physicians not to forget the importance of doctor-patient communication.

If a patient points out a hazard at the doctor's office, he said, it shouldn't be ignored. He added that patients need to be told to report every medication they are taking, including ones prescribed by other doctors, over-the-counter remedies and nutritional supplements.

Physicians also need to give patients clear instructions on prescriptions to increase their compliance and they need to tell patients what symptoms should prompt a trip to the doctor's office or hospital, Dr. Stryer said.

"Patients consider their [doctor] and their health care to be safe," he said. "We don't want to undermine that faith, but we need to make patients aware that health care can be risky and they need to be part of the process of making it safer."

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Be careful out there

Reducing prescribing errors and making your office operate more safely can be done by standardizing practices, reducing reliance on memory and creating systems that can catch errors before they happen or before they reach the patient.

Prescribing tips

  • Do not use abbreviations on prescriptions.
  • Use both the brand name and generic name of a drug.
  • Double check to ensure that pediatric prescription doses are appropriate for the child's weight.
  • Know what other physicians are prescribing for your patient.
  • If using a preprinted prescription pad with the names of all the physicians in your group, circle your name so the pharmacist knows who to call if there is a question.

System suggestions

  • Standardize exam room setup to make items easier to find and easier to restock.
  • Train staff for appropriate telephone triage.
  • Dedicate a common spot for charts needing write-ups, with a separate bin or file for each physician.
  • Mark sound-alike and look-alike packages with stickers and store separately.
  • Don't fall back on "This is the way we've always done it."
  • Institute a policy that no piece of paper is filed until it's been initialed by a physician.
  • Have a patient's chart available every visit with the latest information on referrals and hospitalizations.
  • Develop a redundant, two-person system to check that lab results get delivered to your office.
  • Document when test results or x-rays are received.
  • Emphasize compassion, competence, communication and charting.

Sources: Agency for Healthcare Research and Quality; American Academy of Family Physicians; American College of Physicians; Robert Gillette, MD; James Mold, MD

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External links

"Management of Laboratory Test Results in Family Practice," Journal of Family Practice, August 2000 (link)

"Preventing Errors in Your Practice: Prescription Writing to Maximize Patient Safety," Family Practice Management, July/August 2002 (link)

"Meeting Takes New Tack On Patient Safety," FP Report, November 2003 (link)

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