In his editorial for the newsletter, Prescriptions for Excellence
in Health Care, David B. Nash, MD, MBA, dean of the Jefferson School of
Population Health at Thomas Jefferson University, asked, “Is there a
specific point along the health care delivery continuum at which the risk for
compromising patient safety and quality care is dangerously high?” Nash
concluded that transition of care (TOC), the brief moment when a patient leaves
their primary provider and is received by a specialist, has the greatest
possibility for miscommunication of important patient information and
documents, potentially leading to misdiagnosis or medical error. O&P
practitioners and their patients are certainly a part of that delivery
continuum, working in conjunction with primary care physicians, surgeons and
occupational or physical therapists on a daily basis. O&P professionals
risk
documentation or
medical errors without practicing the necessary patient safety
precautions in a clinical setting.
What is a medical error?
The Institute of Medicine (IOM) defines a medical error as the failure
of a planned action to be completed as intended or the use of a wrong plan to
achieve an aim. Common occurrences of medical errors include adverse drug
events, surgical injuries, falls, burns, improper transfusions or death. Error
rates are most common among intensive care units, operating rooms and emergency
departments, according to IOM’s To Err Is Human: Building a Safer
Health System.
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| © iStockphoto.com |
The numbers are daunting. According to the IOM landmark report, at least
44,000 people and perhaps as many as 98,000 people die in hospitals each year
as a result of preventable medical errors. Taking into consideration additional
care due to the errors, lost income, household productivity and disability, it
is estimated that the cost of these errors is between $17 billion and $29
billion annually. Most in the patient safety field believe the IOM estimates
are low. The CDC reported that more than 100,000 died in 2006 from hospital
acquired infection alone. New data emerged in April suggesting that medical
errors are ten times what the IOM estimated.
How is medical error prevention taught?
Medical errors and patient safety are covered in different ways. Medical
error prevention is taught in O&P schools and practiced in the clinical
setting. But what is being taught? Can those lessons be improved upon at the
master’s level?
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| Dennis E. Clark |
When an O&P student is in school, at some point he or she will
ambulate a patient on a diagnostic socket and will learn how to dynamically
align the prosthesis. In that process, he or she will be instructed on what to
look for before a transfemoral or transtibial patient applies weight to the
prosthesis. Practitioners must be certain that the device is ready for weight
bearing. Those are critical issues in the process, according to Dennis E.
Clark, CPO, president of the Orthotic and Prosthetic Group of America.
Each practice will have a process that they use — a policy and
procedure for a certain situation. If a practitioner tries a different foot, he
or she can still fall back on their policies and procedures. Are all of the
screws tightened to factory standards? As the practitioner makes changes
throughout the process, they must fall back on those procedures as if it is the
first time.
“When a practitioner gets lax or hurried, they skip a step and that
is when problems occur,” Clark said.
It is important to create a standardized procedure because most
practices employ more than one practitioner. There will be an occasion when
another practitioner examines your patient, even within your own practice.
Clark recommends having a policy in place that is conducive to your
company’s management care style. If documentation is consistent and
thorough then you will not run into problems or miss things from practitioner
to practitioner along the health care line.
Curriculum
Documentation and proper
billing practices are part of the curriculum at Northwestern
University Prosthetics-Orthotics Center (NUPOC). Students are taught to contact
a physician if there are any changes to be made to a prescription.
Practitioners can only fill out a prescriptions if is written. If there is a
problem, they must contact the physician immediately.
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| Thomas P. Karolewski |
“I think you get more of a feel for that when you get into a
residency and a private practice,” Clark said. “Different people use
different methods for documentation. I think it is important to be consistent
from patient visit to patient visit so you or anyone in your practice who needs
to can take a look at your patient. This consistency ensures that the
practitioners do not repeat a problem or attempt a solution that has already
been attempted and failed.”
Clark cited
regulatory changes throughout the last decade as one of the
reasons for improved documentation among the O&P industry.
“We are getting better all the time and that leads to a more
professional practice and in turn leading to more consistent quality
outcomes,” he said. “The byproduct of utilizing consistent systems
and protocol is that you have a better chance of realizing what works in your
practice and what is driving the types of outcomes that you are looking for. If
you do not have a protocol, then how do you know if you are maximizing your
potential?”
Patient safety
Patient safety is a different subject, according to Thomas P.
Karolewski, CP, FAAOP, director of prosthetics at NUPOC and member of the
O&P Business News Practitioner Advisory Council. Model
demonstrators visit NUPOC and the students work with them in a clinical
setting. Karolewski’s number one priority is patient safety.
“We make sure that before any prosthesis goes on the patient, the
faculty examines everything from sharp trim lines in the upper limb to exposed
cables that could damage or hurt the patient,” he said.
The students’ interaction and bedside manners are closely
monitored. Bedside manner is just as crucial to patient safety as a crack in a
prosthesis. If there is an interaction that is considered a personality
conflict, the situation is immediately addressed.
The students are also taught spotting techniques and at NUPOC, there is
a therapist who teaches the students how to properly monitor the patients’
first steps with a prosthesis. If there are two students per each patient who
is walking, one person will monitor alignment while the other is spotting.
“When we talk about lower extremity prosthetics, since they are
weight bearing, we really need to pay attention,” Karolewski said.
“If at any point we hear any noises, the patient needs to sit down
immediately. There are certain people we do not let outside the parallel bars
if we do not feel comfortable. We have some younger, more active individuals we
let walk in the hallways after we wrapped the prosthesis in fiberglass
material.”
Patient safety is planned to be a part of NUPOC’s master’s
program. They are also discussing the possibility of collaborating with
Feinberg School of Medicine, Northwestern University.
“We are going to offer how to teach bedside manners, for
example,” Karolewski said. “Our medical school has 20 or so treatment
rooms and they have video cameras. We can watch the interaction between the
student and the patient. A professor can critique it afterwards. Patient
interaction is something we have in our plans.”
Error prevention during TOC
Karolewski found that the burden of responsibility regarding gait
training has been thrown onto the O&P industry. His students are taught
more in the realm of initial gait training because O&P practitioners are
the first people with whom the patient takes a step. Due to this increased
responsibility, the onus is on the O&P practitioner to form a good rapport
with the physical therapist, occupational therapist and/or physician.
“Do not complain about the care your patient is receiving if you
are not going in there and setting the standards,” Karolewski said.
“If you want your patient, who just donned this brand new technology, to
get the best care possible, you have to set the standards. Work with the
physical therapist and tell them this is how the prosthesis functions, this is
what I think you should do and these are the muscles or the gait training you
should work on. Maybe the therapy staff has never seen that type of technology
or prosthesis before. If they do not know how it functions, you can not expect
them to teach it properly.”
Team approach
Karolewski recalled his early days in the profession when clinics were
in vogue.
“You do not hear much about it now, but when I was in school, the
team approach was big,” he explained. “We had collaboration between
the practitioner, physician, and therapists, nursing staff and maybe a social
worker or psychologist. I think it is imperative that the other practitioners
have an open house. I tell my students have them come into your office so they
get to see your facility, meet the staff and bring in a patient and show them
how you operate.”
Residents should visit the hospitals and conduct in-services with the
therapists. Do not be afraid to bring a patient with you to show a therapist
how to use a component.
“Show [the therapist] a patient with a C-leg for example,”
Karolewski said. “Show them the modes and capabilities of the knee. Show
the therapist how they can help develop a plan for a solution.”
