Capstone Video: Preventable Death
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>> So I’ll make sure that cardiology gets a copy of this report and that should do it for this patient, which brings us to Hastings, Robert. Did everyone get a chance to review this record?
>> Oh, yes. This was sad.
>> How so?
>> Well, Mr. Hastings was a young man. He was in a traffic accident. Not his fault as far as we can tell but he ended up with an acute subdural hematoma.
>> He was here on vacation with his wife and three kids so we didn’t have access to his medical records, but he was unconscious and unstable so we had to treat him. As it turned out, one of the medications that we administered was one he was allergic to and we lost him. He never regained consciousness.
>> Okay. So let’s [inaudible] on this, shall we?
>> So what are the legal ramifications for this case?
>> Well, correct me if I’m wrong Dr. Perkins but we need to report this to risk management if we haven’t already because they need to determine whether or not the hospital can be held liable for his death since we didn’t know about his allergy.
>> I would think the reasonable person rule would apply here, wouldn’t it? I mean, as I understand it neither the physician nor the hospital is held liable if they acted as if a reasonable person would under similar circumstances. Now you had to act. You couldn’t get the required information, and so you did what you needed to do.
>> Well, I would think so but we’ll see what risk management says. You know, we’re still pushing for a more centralized way to get basic medical information quickly. I really want us to be able to access patient records electronically through record linkage so we’d have access to patient’s longitudinal records. We could have accessed this patient’s records quickly and easily. Perhaps we would have been able to save him provided that the allergy information was already documented.
>> Or if the patient had a PHR.
>> A personal health record. It’s sort of an aggregate of all of the person’s health information or at least anything you’d want people to have access to in an emergency. It can be carried in a binder, but it’s a lot more convenient to put it on a portable storage device or even up on the web. PHR’s could prevent tragedies just like this.
>> Okay. Well, let’s get moving on this. We have a lot of ground to cover today.
- What legal issues can you identify?
- What could have prevented this death?
- What role could electronic health records have played in this situation?
Capstone Video: Assessing the Compliance Plan
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>> So listen to this. My husband used to work for a company where they had this huge display on the conference room wall that you’d swipe your card through when you came in. And it would display minute by minute how much the meeting was costing the company. It was a thing of beauty. It really was.
>> Let’s get starred we only have the room for a little while. So the reason I asked you here today is to go through the compliance plan that we wrote. And to evaluate whether any changes need to be made.
>> It’s been two years, but I think it’s still a plan.
>> Well, I think so too. But I still have to make sure that everything is accounted for.
>> At most, it needs some minor updating. I mean, there are some reimbursement rules they’ve changed. We should update those. Some organizational changes. Departmental changes. We should make sure those are addressed. But really I’m pretty proud of this.
>> Well, not to rain on anyone’s parade, but I’m not completely satisfied that people are always sticking to what’s in the plan. For example, I don’t think anyone’s verifying the DRG’s or checking for CC, no CCs. The department that I thought was doing it thought somebody else was doing it. And they thought somebody else was doing it. And it’s all documented, they’re just not following it.
>> Well, I’ve been sifting through the reports. And we’ve got a lot of instances where people are clearly not following the plan of action set forth.
>> At all?
>> I’m not saying at all. But in terms of counseling, training.
>> Yeah, add termination to the list. I don’t know what’s happening in HR, but they are not following the plan at all.
>> The plan is great.
>> Oh, yeah.
>> It is. It’s a great plan.
>> Okay, then. We’ve certainly identified the problem. We have a great plan that nobody’s following. So how do we fix this?
>> Well, obviously, we have to start enforcing the rules if no one’s going to take the initiative of follow it themselves.
>> But we just can’t start enforcing them. I mean, we almost have to treat this as if it was a new plan. So, all right, so we run training sessions for staff and management. And we cover all the rules. I mean, there should be ongoing training to reenforce compliance with the compliance plan.
>> That’s great. That’s a great idea. But isn’t that what we did the first time? How do we keep it from all happening all over again?
>> Incentives for following the rules. Punishment for not following them.
>> Maybe. Maybe it doesn’t have to come to that. For instance, one thing we could go is assign specific tasks to specific individuals within the document itself. Okay, if you’re in the street and you yell “Somebody get an ambulance.” Chances are pretty slim that somebody’s actually going to get you an ambulance. But, if you say “Hey, you in the red sweater, get an ambulance,” you’re much more likely to get a response. So all I’m saying is that assigning specific tasks to specific individuals is a good way to get them to act.
>> I like that. We should specify the communication channels again. Making sure everybody knows, not only what it is they’re assigned to do, but who they should be reporting to about it. Who they should go to to ask questions, so on.
>> What if we set up a centralized repository for reports and analysis?
>> Oh, and that repository would be tasked with maintaining a specific set of reports. That way, if somebody’s not doing what they should be doing, the repository would be the first to recognize the gap. And we’d know immediately who was responsible for it.
>> I’m worried about adding more layers.
>> It’s not layers so much as checks and balances. And we can keep it lean. Look I say we divvy up the tasks among us and meet again on Monday so that we can get these revisions underway.
>> Okay, that works.
- Why is compliance so important?
- Identify the problems presented in this case. What action(s) should be taken?
- How can they get people to follow the compliance plan? How often should it be evaluated?