By Lisette Hilton, contributing writer, July 01, 2011
Like doctors in other specialties, dermatologists are feeling the pressure to identify, report, and implement processes to reduce errors, as the focus on patient safety moves from the inpatient to ambulatory setting.
“In medicine, in general, there is a move to close the gaps and create safety nets to improve patient safety,” said Dirk Elston, MD, director of the Ackerman Academy of Dermatopathology in New York.
Institute of Medicine reports, starting with “To Err Is Human: Building a Safer Health System,” released in 1999, compelled physicians and other health care providers to face their vulnerabilities, according to Dr. Elston.
“We’re owning up to the fact that people do make mistakes, and there are ways to prevent them by putting engineering into place that reduces the chance of errors occurring and creates safety nets to catch errors when they occur,” he said.
Dermatology-specific safety issues: The biopsy
Literature collected by the American Academy of Dermatology’s Performance Measurement Task Force suggests that gaps in dermatologic care occur more often with surgeries and biopsies. This realization triggered the development of a biopsy follow-up process measure, which was submitted for inclusion in the Medicare’s Physician Quality Reporting System (PQRS) in 2012.
“There are many steps involved in the labeling, transmittal, processing, and reporting of those biopsies,” said Dr. Elston, who chairs the Academy’s task force.
Finding the site of a recent biopsy can be a problem in dermatology practices. Dermatologists, according to Dr. Elston, are very adept at doing biopsies that don’t leave undue scars — so good, in fact, that biopsy sites may be hard to find when patients return for surgery.
“On the other hand, the patient may have many scars from prior procedures, and the biopsy site gets lost in a sea of scars. In either case, which is the recent biopsy?” he said.
Pre-procedure photographs and diagrams have been cited as the best ways to accurately identify biopsy sites.
Another common error is the mislabeling of specimens. In a typical scenario a dermatologist may perform three biopsies (a, b, and c) on a patient, on the same day. Biopsy b is almost always in the right bottle but a and c might be switched, because of errors in communication between the dermatologist and the assistant.
“For the patient, it can make a big difference whether the melanoma is in bottle a or c,” Dr. Elston said. “There are all sorts of variations on that scenario.”
Following the universal protocol of the Joint Commission should help avoid biopsy mislabeling, according to James S. Taylor, MD, consultant dermatologist and the quality improvement officer for the Dermatology and Plastic Surgery Institute at Ohio’s Cleveland Clinic. “It’s where, before you finish the procedure, you double check that the specimens are labeled correctly, with the correct patient’s name, biopsy site, and differential diagnosis,” he said.
The next step is the follow-up. If, for example, a report comes back as malignant melanoma, there’s the issue of timely reporting to the patient. Do you send a letter? A letter could be lost in the mail. It’s critical, according to Dr. Taylor, that the dermatologist or staff records the pathology or laboratory results in the patient’s chart and documents when and how the patient is notified. “For skin cancers I recommend both written and verbal communication with the patient,” he said.
“The important thing is to make sure that you tell patients that they will hear from you one way or another, and, if they haven’t, they should call your office,” Dr. Taylor said.[pagebreak]
The AAD’s Performance Measurement Task Force has been identifying gaps in care through its participation in PQRS. The National Quality Forum, a voluntary consensus standards body that reviews and endorses quality measures, has endorsed four measures relevant to dermatologists: Melanoma Coordination of Care; Over Utilization of Imaging Studies in Stage 0-IA Melanoma; Melanoma Continuity of Care Recall System; and Biopsy Follow-up. Dermatologists can currently report on the three melanoma measures in the 2011 PQRS program. The Biopsy Follow-up measure is tentatively slated for inclusion in the 2012 PQRS program. See www.aad.org/education-and-quality-care/performance-measurement-and-quality-reporting for more information on measures and the Medicare quality program.
Dermatologists can avoid fire hazards, electrical shock, and more with such safe practices as electrical equipment grounding.
“We use electrocautery; so, proper grounding of all the electrical equipment (lights, sockets, everything in the room where the surgery is being done) is important,” said Dr. Elston, who was lead author on a continuing medical education article about patient safety in the August 2009 Journal of the American Academy of Dermatology.
The proper use of electrocautery is another area where dermatologists need to be particularly aware of patient safety. Dermatologists need to consider if the patient has a pacemaker or implantable defibrillator, as well as to decide whether to continue anticoagulation for patients.
“If you continue the anticoagulation in someone who needs it for medical reasons, the patient may develop a hematoma. If you discontinue it, the patient may have a stroke. So the usual guideline is that if the anticoagulation is needed for a medical reason, it is not discontinued,” Dr. Elston said.
Other important safety considerations for surgical cases include sterility and infection control and proper patient positioning.
“Most injuries to patients in the office setting from surgery are from the patient fainting and associated falls,” Dr. Elston said. “Proper positioning of the patient during injection of anesthesia is important.”[pagebreak]
Medication errors preventable
The most frequent errors in medicine, in general, relate to medications, according to Dr. Taylor.
Dr. Taylor suggests that in order to avoid medication errors, dermatologists should think in terms of the five rights: right drug, right patient, right dose, right route (orally, intramuscularly, or intravenously) and right time.
There are many ways to prevent medication errors. One safety net is electronic prescribing, which can be implemented with or without an electronic medical record (EMR), according to Dr. Taylor. Dermatologists can receive government incentives to implement e-prescribing and face penalties beginning next year for failure to do so. See www.aad.org/hitkit for more information.
The technology eliminates the problem of handwriting illegibility, because prescriptions are computer-generated and printed. It’s not foolproof, however.
“If, for example, you have a drug with three different dosages: 100mg, 200mg, and 300mg, you may need to give the patient 100mg, but highlight 200mg accidentally,” Dr. Taylor said. “You have to proofread the prescription with electronic prescribing. It does not avoid all errors, but, overall, the odds are that it improves prevention of medication errors and expedites processing.”
Dermatologists and staff should avoid interruptions when filling a prescription, according to Dr. Taylor. A physician writing a prescription might be interrupted by a nurse, lose his or her train of thought, and make a mistake.
Dermatologists should avoid prescribing look-alike and sound-alike medications and shouldn’t use abbreviations when writing prescriptions.
“To avoid confusion, include both the generic and brand name; the drug strength; and the dosage form — whether it’s topical, oral, etc., the amount, directions for use, purpose, and refills in addition to the patient’s name and address,” Dr. Taylor said. “The use of tall-man’ letters is also helpful and is now used by our electronic record. For example, write hydOXYzine to avoid confusion by the pharmacist with HydrALAZINE.”
Latin and other abbreviations are a significant source of medication errors. Dermatologists should spell out drugs and dosages, even when using electronic prescribing, according to Dr. Taylor.
“MTX is commonly used by dermatologists as methotrexate, but others might confuse it as Mustargen,” Dr. Taylor said. “HCT commonly is hydrochlorothiazide but a pharmacist might consider it to be hydrocortisone.”
Avoid verbal orders if at all possible. If you have to give a verbal order, enunciate slowly and distinctly. Spell out long and difficult drug names and specify concentrations. Then, have the nurse or pharmacist repeat your verbal order back to you.
Carefully calculate dosages. Make sure medications are labeled correctly and identifiable.
“Botulinum toxin, for instance, is diluted with bacteriostatic 0.9 percent normal saline, but some practices might also be using concentrated sodium chloride for other procedures; so, it would be absolutely critical that you not mix up those two vials when preparing botulinum toxin for injection,” Dr. Taylor said.[pagebreak]
Plan; then, have a backup
The Joint Commission’s universal protocol and safety check list for hospital outpatient departments, according to Dr. Taylor, recommends that physicians, including dermatologists performing procedures, such as Mohs surgery, should conduct a pre-procedure verification including allergies, medications, informed consent, right equipment, and key laboratory results and then take a time out to check for the right patient, the right side and site, and the right procedure, at the right position. Everybody in the room should agree or voice concern if they don’t. The post-procedure sign out checklist should include correct specimen labeling and whether the patient received and understands postoperative instructions, he said.
Failure mode analysis, according to Dr. Elston, is an important patient safety practice that involves looking at what could go wrong and preparing for it. It requires that you ask questions, such as: What would happen if a patient had a myocardial infarction while in your office? Do you have all the equipment in place or are you in an office complex where someone else is supposed to respond? If you’re in a group practice, is someone else supposed to respond? How do you reach that person? Do you call? What do you do if the phone lines are down because of a storm? Do all staff members and physicians know where the fire alarm is? Does everyone know where the fire extinguisher is? Does everyone know what to do with a patient if the fire alarm goes off?
The goal of the analysis is not only to develop a plan, but also to create a backup plan.
“When an emergency occurs in the office, everyone’s adrenalin is running. You want to be sure that everyone knows what they’re supposed to do, there’s a clear plan of action, and there have been practice drills. Instead of panicking, everyone knows what they’re supposed to do, and they also know what the backup plan is,” Dr. Elston said.[pagebreak]
Quality of care, which includes avoiding preventable errors, could affect dermatologists’ future reimbursement and certification status, according to Dr. Taylor.
“Payment to hospitals is going to be based, in part, on patient satisfaction surveys. I think that will eventually be the case in ambulatory settings,” he said. “Quality and patient safety issues are now part of maintenance of certification.”
Preventing errors requires not only reflection on one’s practice, but also staff buy-in.
“This requires that you create a culture of patient safety in your office,” Dr. Taylor said. “The culture is one of fixing system’ issues rather than blaming individuals. Everybody is in this together, creating a team approach to taking care of patients.” dw
The Academy is developing a patient safety section on AAD.org that will include information on the most common safety issues encountered in dermatology practices and useful downloadable tools such as checklists. Look for this resource to launch later this year.
The Academy has partnered with DSS Research to bring a Patient and Peer Communication Survey Program to its members. These surveys are approved by the American Board of Dermatology (ABD) to help fulfill part of the Maintenance of Certification-Dermatology (MOC-D) Component 4 requirement and are available online at www.aad-dss-survey.com.