Take an advocacy role in preventing medical errors in your hospital
Take an advocacy role in preventing medical errors in your hospital
Continuity of care, timeliness, and appropriateness are key factors
As patient advocates, case managers can play an important role in preventing errors or addressing any event or delay in care that could result in serious complications for the patient, says Hussein Tahan, DNSc, RN, CNA, commissioner for the Commission on Case Manager Certification and immediate past chair for the Commission on Case Manager Certification.
Many medical errors are caused by omissions or delays in care, and this is an area where case managers can and should take the lead, he adds.
John Banja, PhD, associate professor at the Center for Ethics at Emory University in Atlanta, points out that a 1997 study placed average cost of a medical error at a hospital at between $4,000 and $5,000.1
"Errors help drive the cost of health care up. It’s already expensive, and errors or inefficient care only compounds the problem," he says.
All case managers’ duties are interrelated, and they all help to make sure that the patient is safely and effectively treated and released, whether it’s ensuring access to care, medication reconciliation, timely transition of care, or appropriate discharge to home or placements in another facility, Tahan says.
Case managers should not concentrate so much on reimbursement issues that they fail to be concerned about other issues of patient care, such as appropriateness of services that the patient requires based on his or her medical, psychosocial, and financial conditions, he says.
In addition, timely care is important from a patient safety standpoint as well, because it ensures appropriate, timely, and safe care progression and outcomes, Tahan points out.
Case managers should ensure that tests and procedures are performed in a timely manner, not just to cut down on avoidable days but to make sure the patient’s condition is better managed, he explains.
When a patient’s plan of care depends on the result of a test and the procedure is delayed, this delays the start of his or her treatment and may result in untoward events and preventable conditions. This is an area where case managers can make a difference, Tahan adds.
For instance, if a patient needs an MRI before the physician can decide on a treatment, the case manager should make sure the patient undergoes the test in a timely manner and that the physician gets the results so the decision about the plan of care can be made and the treatment started as quickly as possible.
Ensuring the right tests and procedures are being done and that the patient has access to the services he or she needs leads to a more efficient plan of care and a more desirable outcome. For instance, if a consultation is requested but hasn’t been completed, the case manager should contact the specialist and make sure the consultation is conducted and that the results or recommendations from the consult are incorporated into the patient’s plan of care.
"If case managers are diligent in identifying delays and variances and creating a plan of action as they identify them, hopefully they can resolve the issue before serious consequences take place. When a patient receives care in a timely manner, the care provided will be safe," Tahan says.
Case managers should frequently review the care plan and the medical records to identify whether things, such as treatments, tests, and procedures happened when they should have. They should communicate their findings with the health care team and ensure that the plan of care is progressing according to expectations.
"Delaying tests may not allow the team, including the physician, to appropriately address a patient’s needs and could result in harm to the patient. Case managers should monitor access to care, manage variances and delays in testing and treatments/services, and make sure a good plan of care is in place," he adds.
Case managers are in a position to reduce the risk for medical errors as transitions in care occur from one health care setting to another, from one provider to another, or from one level of care to another in the same hospital, Tahan points out.
"As transitions of care take place, there is always an opportunity for someone to drop the ball, which may result in a patient’s harm or an untoward event. There is the potential for errors to occur as patients move through the continuum of care from the acute care facility to a post-acute facility, when they move through an individual organization, such as from the emergency department to an inpatient bed, or when they transition from one specialty to another, such as from cardiology to gastroenterology," he says.
Case managers should work to ensure that clinicians at the receiving department or facility are aware of anything necessary for continuity in care, for a patient’s well-being and functioning and to keep the patient’s health condition stable, he adds.
When patients are admitted from the emergency department to an inpatient bed, the case manager should review the acuity of the patient and match the resources the patient will need to an appropriate care level or inpatient bed.
For instance, if the patient needs a bed in the intensive care unit, the case manager should ensure that the patient is not moved to an area of less acuity because there isn’t an ICU bed available.
The emergency department staff focus on the immediate, urgent needs of the patient but do not always monitor other pre-existing medical conditions unless they are directly related to the immediate chief complaint.
"Case managers can play an important role in ensuring that the patient’s treatment plan is appropriate at all times and dependent on the patient’s condition," he says.
For instance, if a patient comes in with chest pain, the emergency department staff may focus on relieving the chest pain and identifying if it’s cardiac in nature. However, the patient may be taking medications for a chronic condition such as diabetes or high cholesterol and will need to continue taking the medications in the hospital.
"While a patient gets to an inpatient bed, the case manager should review the medical record and interview the patient to make sure the plan of care addresses pre-existing medical conditions and not just the treatment instituted in the emergency department that was based on the chief complaint the patient presented with in the ED," Tahan says.
Case managers should make sure that the medication regime the patient is on at home or another facility continues in the acute care environment.
"If a medication is stopped, it should be because there’s a reason for it and not because it was an oversight by the physician or nurse practitioner," he adds.
When a patient is being transferred from acute care to a rehabilitation facility or a nursing home, the case manager should make sure that the receiving facility gets all of the appropriate medical information including the prescribed medications so continuity of care can be enhanced.
"Case managers should make sure the receiving facility is aware of the kind of treatment that needs to take place so that it can be continued in a safe and timely manner," he says.
Patient and family education is another piece of the patient safety process.
"Educating patients about their options and right to care and making sure they are engaged in informed decisions about the plan of care is important. Case managers should also make sure that patients or their families are well aware of their expectations for self-care when they are discharged from the hospital," he says.
For instance, make sure that the patient or a caregiver is capable of taking care of the wound or dressing and that the patient is able to take his or her medicine.
"Case managers should give their patients the latest information and patient education materials in a language they can understand so they know what they need to do and be more adherent to their care regimen," he says.
Educational materials should be at a fifth-grade reading level so patients can comprehend them. Since patients may not always be able to retain the information they receive in the hospital, case managers should provide written information that they could refer to after discharge to fill in any gaps they may have missed while in the hospital.
Banja notes that the Leapfrog Group, an organization concerned with safety and quality in health care, has begun a pay-for-performance program to reward hospitals for their performance in both the quality and efficiency of inpatient care. Leapfrog Hospital Rewards Program can be licensed and implemented by employers, health care coalitions, and health plans for pay-for-performance initiatives.
Rewards suggested by Leapfrog include bonus payments, higher reimbursement rates, public recognition, and/or increased patient market share.
"Health plans are taking a serious look at whether or not they should be contracting with hospitals whose patient safety measures are somewhat less than they should be. They’re betting that following those practices will result in greater patient safety that might translate into lower health care costs," Banja says.
Reference
- Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA 1997; 277:307-311.
[For more information, contact:
- John Banja, PhD, Associate Professor, Center for Ethics, Emory University, Atlanta. E-mail: [email protected].
- Hussein Tahan, DNSc, RN, CNA, Nursing Director, Cardiovascular Services and Care Coordination, Columbia University Medical Center, New York-Presbyterian Hospital, New York City. E-mail: [email protected].]
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