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.

	© 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?

	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.

	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.”

Clark believes TOC is a major factor in why O&P licensure is so important. O&P practitioners can not only provide prostheses and orthoses, but also manage patient care.

“We are paid not only for the product but primarily for the service we provide,” Clark said. “Part of that service needs to be in a pro-active nature. If there is a problem with patients that are already at risk, such as diabetic patients with other risk factors, we must make an appropriate referral back to the physician. Practitioners can not be afraid to communicate back to the physicians. They will not think less of us. In fact, the opposite is true. It is just a matter of being a professional.”

Mitigate the risk

Clark recommended being absolutely certain of a patients’ ambulatory status and ability, along with how much assistance or help they will need in the clinical setting.

“Be there to help even if the patient doesn’t need help,” Clark explained. “The utilization of a gait belt is necessary even if the patient protests a little bit.”

If the patient does protest, Clark recommended citing the practice’s policy. Explain to the patient that you will only intervene if necessary. Create a checklist with respect to the fabrication process. How are things attached? How do you know they were done properly? You can start in the lab. Patient assessment and consistent reliable processes are crucial in order to be certain that the diagnostic socket was appropriately handled.

Many patients are using care extenders prior to the practitioner visit. Clark insisted that the O&P practitioner must train other practitioners on how to apply safe standards within the practice.

“A socket breaking down in your parking lot is totally avoidable if you are following guidelines or a set of criteria within your practice,” Clark said.

Informed consent

In O&P, where there is a certain trial and error embedded in the landscape of the profession, an informed consent document or process is the perfect place to reset the patient’s expectations.

“You are giving them the choice to have a new solution that may help them in ways old solutions can not, but there are new risks involved,” Martin J. Hatlie, JD, chief executive officer, Project Patient Care said. “If those risks are explained, people are better empowered to make the decision best for them and most people will understand them.”

Warning signs

Practitioners must recognize the warning signs. The standards that are set in the classroom educate future practitioners on recognizing a problem. It always goes back to proper documentation. Clark said that practitioners tend to document correctly when things are running smoothly with a patient but are more hesitant to document when things are not going as planned.

“We need to be just as clear when we are not getting the results we want,” Clark said. “Document what your change in management is going to be and your expectations going forward. You would like to make the right call and have everything go well every time but that is just not the case sometimes.”

Disclosure and honesty

What should a practitioner do if they make the wrong call?

“It is a good idea to start communicating with a patient that is unhappy or they think is unhappy as soon as possible,” Hatlie explained to O&P Business News. “Even before you know it is an error, oftentimes a practitioner or physician can never tell for sure. They just know something has not gone right.”

Why the procedure or the fitting did not go as planned takes some investigation. But from the patients’ point of view, they have a right to know the situation. People are entitled to the information about their own bodies. That type of language can be found all the way back to the Hippocratic Oath and is firmly embedded in the modern understanding of human rights, according to Hatlie.

Physicians and practitioners may think that it is better not to say something before they have all of the answers. But what they miss is the opportunity to have a difficult conversation, but one that demonstrates that there is a communication flow with the patient. Several studies have consistently shown, according to Hatlie, that patients want to know if something is wrong and they want hear it from someone they trust.

“It is a perfect role for the doctor to play because that is the person the patient wants to trust,” Hatlie said. “What I see, way too often, is that when a doctor thinks there has been a mistake, they let the patient management staff handle it and that just is not as effective as the trusted authority figure having a conversation with the patient.”

There is no guarantee that an immediate conversation with a patient will eliminate litigation. But what Hatlie can say with almost certainty is that a lawsuit will be easier to settle and the payout will be less significant if a conversation between a practitioner and patient has taken place. According to Hatlie, the best case scenario is the communication between practitioner and patients leads to increased trust even after the event. In the worst case, communication diffuses the anger of the jury when the physician or practitioner has followed the proper procedures.

“We must remember our role as a prosthetist and that is to give function back,” Clark said. “That process has to be safe. Following standards and a checklist that is part of your policies and procedures will help maintain that safety. No one is perfect, so if you have these policies in place and the unthinkable happens, a practitioner can at least go back and say they did everything to mitigate that risk.” — by Anthony Calabro

For more information:

• Classen, David. Global trigger tool shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs. Available at: http://content.healthaffairs.org/content/30/4/581. Accessed April 13, 2011.

• Kohn L, Korrigan J, Donaldson M, Eds. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine. Washington DC: National Academy Press; 2000.

• Nash, David B., Lost in transition. Prescritptions for Excellence in Health Care. 2010;10:1-2.