Quality Improvement in Healthcare Episode 2 | Transcript
Erik: And we're here this is the Baylor College of Medicine Resonance Podcast, I am your host Erik Anderson, and I'm sitting here with somebody, do you want to introduce yourself?
Brice: Yeah my name is Brice Thomas, a third year medical student, happy to be here.
Erik: And I should say virtually sitting here due to COVID.
Brice: Yes yeah that's what we do these days.
Erik: Yeah, so this is part of our IHI mini-series, which at this point I believe you've probably heard a few episodes and had a little bit of introduction. So Brice is going to just tell us a little bit more about the episode before we just jump right into it.
Brice: Sounds good, so this interview is about medication error. This is a topic that's not really discussed until something goes wrong unfortunately. So from errors in prescribing and dosing to errors in actual administration, medication errors are more common than you'd think. We have Dr. Lauren Lobaugh, a pediatric anesthesiologist, myself, and Brandon Garcia talk about why these errors occur and what steps we can take to reduce them.
Erik: Yeah no it's a great talk too, I've…you know we've already shot it already so I don't know if that mystique is gone now. But it's, yeah, I'm excited.
Brice: Yeah, so yeah Dr. Lauren Lobaugh, she's a board-certified pediatric anesthesiologist and an assistant professor of anesthesiology at BCM and Texas Children's Hospital. She completed medical school at UT Houston, residency in anesthesiology at Georgetown, and pediatric anesthesiology fellowship at Children’s Hospital of Philadelphia. She first got involved in quality and safety during her residency as part of wake up safe, an initiative sponsored by the society for pediatric anesthesia that focuses on improving outcomes and quality improvement education. She completed a faculty fellowship in Quality and Safety at TCH in 2016 and earned a master's in healthcare quality and patient safety at the Johns Hopkins School of Public Health in 2019. She currently works with the Institute for Safe Medication Practices on an FDA-sponsored safety assessment tool. She also has a busy personal life with two sons at home. In addition to her clinical duties she's involved in the BCM Chapter 4 IHI, including leading courses like Skills and Advanced Topics in Patient Safety and QI.
Erik: That's great, okay well so without further ado, here's the interview.
Brice: All right, welcome. I’m Brice Thomas, a second year medical student currently interested in internal medicine. We're excited to continue our quality improvement mini series today with our guest Dr. Lauren Lobaugh, a pediatric anesthesiologist and expert on medication error. Welcome to the show.
Dr. Lobaugh: Thank you. I don't know if I'd call myself expert, but I do have some knowledge around the topic for sure.
Brice: Nice, you definitely know more than us and our listeners probably so..
Brandon: You were talking to us a little bit about your background. You said you went to McGovern.
Dr. Lobaugh: Well, it wasn't McGovern then but now let's call it McGovern - I went across the street for medical school. I'm from Houston and then I went to Georgetown in D.C. for my residency in anesthesia and that's where I kind of first got involved in quality improvement and patient safety and I don't know how many years ago that was. We don't need to count that far back and I’m not really that old. But I can't count that far back. They all kind of blend together after a while…and I got involved through my residency. And then as well as there was a regional quality improvement patient safety program through Medstar Health, which was the bigger organization I was in. And I kind of just as they say ‘drank the Kool-Aid’ and I continued on my interest in quality improvement patient safety at CHOP, so I did my clinical fellowship in Philadelphia and pediatric anesthesia there and I really got involved with an initiative out of the Society for Pediatric Anesthesia which is called Wake up Safe. And its an initiative focused on improving outcomes in pediatric anesthesia and education of the members at large. And then from there, you know, what do you do after fellowship, you got to find a job. So I wanted to come back to Houston and I got a faculty fellowship in quality improvement while being a part-time pediatric anesthesiologist at TCH, so it was kind of a hybrid year for me. And then I always felt like that wasn't enough. Peter Pronovos is a big person in quality and patient safety that came out of Hopkins, very famous gentleman and he said in a conference I went to in residency once that if you want to lead or be an expert in this field you really need to have the backbone or the foundation, so I applied for my master's at Hopkins and got accepted to um it was all online program. And so I was able to complete my master's in healthcare quality and patient safety. The following year after my fellowship, I found out I was pregnant two weeks after I started the masters.
Brice: Oh wow
Dr. Lobaugh: So that was really poor timing but it never really works, right?
Brandon: I don't think there's any like convenient time for anything in life.
Dr. Lobaugh: Correct. So I continued through that while working full-time and I was able to finish that this last December so now I have my master's.
Brandon: That's awesome.
Brice: Nice, congratulations.
Dr. Lobaugh: And as I've so I've been an attending for almost four years now and I'm involved at the department. I am in charge of our policies and procedures in our department as well as an associate chair for our quality improvement committee and then I'm involved still nationally in Wake Up Safe and have gotten a lot of amazing opportunities to continue that. I was telling Brice earlier today I was on a conference call. I'm on an expert panel for a medication safety assessment tool that the FDA is sponsoring through the Institute for Safe Medication Practices. It's called ISMP, but so that's how I spent my afternoon.
Brice: Very cool and you're heavily involved too in the medical school advising members of our chapter for IHI, the Institute for Healthcare Improvement and also teaching courses, right?
Dr. Lobaugh: So I got involved in IHI um by submitting work when I first came on at TCH and when I was there I went internationally to London to one of their conferences. They're amazing and one of the people there asked me if I did anything with the school, Baylor School of Medicine and their IHI program and I said I didn't. So when I came back I was able to get involved and actually kind of was handed over the the courses that I'm now course director. So I am the course director for the Intro to Quality Improvement and then Advanced Topics. And with the help of a lot of your fellow students particularly Anoosha, I've been able to kind of change that course around so that it's tailored to what you guys want and bring in some really great lecturers that I've never even gotten to work with from Ben Taub, from the VA, Molly Horstman is someone who comes to mind who's very involved in education at the VA. I think Dr. Coleman is going to give you guys your wrap up who is very high up in quality improvement in the Baylor system and has a very important leadership role and I think her lecture is always very well received.
Brandon: That's awesome.
Brandon: It sounds like you have a very impressive record and background in QI what would you say is your passion or your goal in your participation with quality improvement and patient safety? Like what do you personally want to make sure happens?
Dr. Lobaugh: So I think it stems from when you guys…looking back when I was in y'all's shoes in medical school. You start to get your, you know, experience on the wards, and it's frustrating when you're like, why does it take me an hour to contact someone about a simple question or why are there so many different ways to get to the same answer? Or, you know, or just all the frustrations that you see whether it's delays in care or having orders not done correctly. And you know when I first started residency I'll tell you we were on paper charts, so that was a whole other problem. I think that electronic records have helped but they're a problem in itself and so you're going to see these issues. And you can either be a person that says ‘I can't do anything about it’ or you can get involved and try to be part of the solution. And I think that's kind of fitting for how I take on things. And I've always wanted to see if I can help make it better. The personal part is I am in pediatrics, I’m also a mom and so I so I always feel like I want to make health care for children and their families the best possible experience - what I would want for my own child. And so if I can find solutions to make it better then, you know, kids don't have to be… experience medication errors or medical errors in general and I think that's a, you know, very lofty goal , but I think it's important to strive for.
Brice: Yeah, I feel like the stakes in pediatrics especially are just so high or at least I had that feeling on my pediatric rotation. You know, you just want to do everything right. You don't want to…
Dr. Lobaugh: Kids make you nervous?
Brice: Yeah, yeah, you know and parents too! You know? So what I'm hearing from you is that, you know, there are these systemic kind of issues and you can either say like ‘oh well this is just this is a system, i can't do anything about this’ or you know, ‘I can investigate what's going on and try to come up with with the solution.’
Dr. Lobaugh: Yeah and I think it's important that you may not be able to solve the problems of Baylor College of Medicine or Ben Taub or Texas Children's as a whole, but you can, you can propose solutions and try to implement them in a smaller scale. In a ward, in a clinic, in the OR, you know I think the important thing is to start very small and see how your success is and if you're successful then you can grow and spread it. People often try to take off these, you know, big bites.
Brice: Yeah, change the world.
Dr. Lobaugh: Change the world and it's disheartening, so I’ve learned through a lot of failures that if you start small it's a little more achievable.
Brice: For sure. So I'll call you a medication error expert. What are medication errors? What's kind of the , because I know in my reading for this it doesn't necessarily mean that the patient was harmed it could just be, you know, yeah it could be another event yeah or a near miss.
Dr. Lobaugh: I think that that you have to… So medication errors are a small piece. So if you take a step back at the big picture, there's medical errors in general. And you will all experience them in some form or another. I think we have addressed some of these and so they happen less frequently. But still you can get misdiagnoses, you can get wrong-sided surgeries, falls, burns, pressure ulcers, transfusion reactions, or I should say improper transfusions, mistaken identity, and then you have medication errors. And I think medication errors definitely have got a lot of attention, but the big thing is… So how many years ago? 1999, how many years ago was that?
Brandon: That would be 21.
Dr. Lobaugh: So 21 years ago, do you know what happened in 1999? It's very quoted there was a report that came out.
Brice: To Err Is Human?
Dr. Lobaugh: Correct, okay so To Err Is Human came out and that was like huge. People were aghast, because in it… It said that medical errors and I want to make sure I specified medical errors were the sixth leading cause of death.
Dr. Lobaugh: And people were like that's impossible, but really in the two decades since then we've learned that was grossly underestimated.
Brice: Right, because the reporting is not there.
Dr. Lobaugh: The reporting is atrocious and that's a huge problem we have in quality improvement, in healthcare and what it really is more like is the third cause, which is what…
Dr. Lobaugh: I think the literature is a little bit more delayed. We're looking at like 10 year old literature now but it's causing the third cause of death behind heart disease and cancer, which is astounding.
Dr. Lobaugh: So then you have medication errors. Basically, medication errors can be a variety of things associated. They don't necessarily have to cause harm.
Dr. Lobaugh: The thing that I think is crazy is there are some reports when you look up like the statistics of medication errors that the harm or the the ‘after care’ from after a medication is quoted upwards of 40 billion dollars a year…
Dr. Lobaugh: in expense.
Brandon: That's the that's how much it costs to make
Brice: Like just the side effects?
Dr. Lobaugh: So that's how much they believe the care, patient care required or needed after medication errors totals.
Brandon: Okay, okay, so like I said before… I’m very new to QI and to medication error. It's like they've talked about them in medical school and honestly after having been a med student for a little bit I can totally see how that could happen. Because medicine is an ever-changing area and it takes a lot of brain power to keep up, so I can understand. You said that… There was two things you were talking about with medication errors itself. One was that it was the sixth leading cause of death, but under reported. I wanted to ask, what is the rate like currently from your understanding of medical error? And what is the underlying reason for why it was so underreported? Is there like a fear or stigma regarding, like, making mistakes? Like what would you say is the underlying cause of that under reporting?
Dr. Lobaugh: So to clarify, medical error was considered the sixth leading cause of death 20 years ago when that first report came out - the IOM report. Now it's considered to be the third leading cause of death.
Brandon: Is that because of more error or more reporting?
Dr. Lobaugh: More reporting… A better understanding, because from the 90’s on…the past 20 years, quality improvement went from being a very novel concept to now much more commonplace. You guys have it as part of your education in medical school. You're exposed to it in residency. There are whole parts of the administrative aspects of hospitals focused on quality and patient safety that weren't there 20 years ago. So I think that there is much more reporting, so it's considered to be the third leading cause of death. However, to ask for a rate, that's like impossible to quantify. There are studies that try to look at that, but I think that there is a stigma with reporting. There is worry about shame and blame, which is a huge culture problem in a lot of hospitals. And then there's also not knowing you committed an error… If let's say there's no significant harm to the patient, do you know that you made an error? Perhaps you made an error of omission. You forgot to give an antibiotic. Do you know that you did that? Can you, you know… how does that get checked? And so I think a lot of stuff goes under reported. And in medication errors there are lots of steps along the way. So I’m an anesthesiologist, so we'll get to kind of what it's like to be in that role in medication errors later. But in general, you want to write a medicine for your patient , right? You're on the wards. You order it. So you put in the order. It's a… now you guys probably order it in Epic, you're not really writing orders. But then that order is transcribed, it's dispensed, it's administered, it's documented and then it's monitored. So each of those steps along the way all have the potential for a medication error. The most common is the prescribing. And that's where physicians, mid-levels, people who have prescribing powers or abilities can be the most vulnerable. You can do the wrong medication, you can do the wrong route, the wrong dose, the wrong frequency and it's really hard to keep up. How many times, you know, are new drugs coming out? Or new dosages? You have to tailor it. In my world in peds, you then have to put in weight based…
Dr. Lobaugh: …and apply that to it, so I think there's lots of opportunity for error.
Brice: I just wanted to like reiterate the scope of this kind of issue, you know, it's huge! I was reading that 1.3 million injuries per year occur because of medication errors and even one death per day in the U.S. I think that was the FDA that said that.
Dr. Lobaugh: Yeah, I mean I think that that is unknown. There are other things I was looking at. Some of the kind of the current papers that have come out as of this year and one of them said 7,000 to 9,000 people die every year. So I think that deaths are very trackable…
Dr. Lobaugh: …because you need to if someone dies… they do an investigation. There has to be a cause of death and so I think those numbers potentially could be a more reliable factor. But we just don't know with the medication errors for sure.
Brice: How do you think we reduce these errors? What are… what are some ways we can do that?
Dr. Lobaugh: So I think that the biggest thing is to focus on systemic issues and the fact that the system is failing the providers and the patients. It's wrong to label it as the providers are failing their patients. And that's one thing I think is most crucial if you're interested in quality improvement is to remember that you are human and you… making errors, you know, The Swiss Cheese Model… human factors. There's a huge study in just human factors in these errors and so I think it's important that we demand systems-based solutions for these problems.
Dr. Lobaugh: So there's a lot of different areas you can focus on. One is in medication errors, patient information. So do you guys know what a red rule is?
Brandon: I do not, so I'd love for you to tell me.
Dr. Lobaugh: So a ‘red rule’ is something that a hospital abides by that cannot be broken. It is a rule that if you do not follow, the potential consequence is termination. So one of the big red rules is using patient identifiers. So you should use two patient identifiers when administering your medicine or verifying a patient. So I can't just say this is Brandon Garcia, he's here for surgery today. I have to say ‘this is Brandon Garcia, your date of birth is 6/10/1990 and this is your MRN.’ So those are two identifiers that are exclusive to you. Because if right next to you in the next bed is Brandon Garcia, what if I just said the name and I didn't do those other identifiers? I could have the wrong Brandon Garcia. So red rules are a big thing. They can be dangerous, because it's an absolute, right? So if you don't want to have something that needs exceptions, but red rules are one way… Also, another thing that you guys probably participate in a lot is updating current medications. So when you're admitting patients on the ward, probably one of the first things they ask is did you get a current med list?
Brice: Yeah, med rec.
Dr. Lobaugh: Medical rec. You want to reconcile the med list, because you want to know what that patient is taking so you can avoid errors there. In pediatrics, it can be standardizing the weight and height, which has already been done but that was one thing… So in the U.S., you're taught pounds, right? And feet? But really in medicine, that's not how we practice. We practice in kilograms or grams and meters or centimeters. So making sure you have that, but there's also, you know, there's so many other aspects… There's drug information, making sure you are identifying high alert medications. So depending on where you've done your rotations on the wards so far… I mean, there's some pretty potent, dangerous drugs. You can get your hands on heparin, insulin, lidocaine, potassium chloride. Two years ago and I don't even know how these things occur, but I had a resident who asked for some potassium and the pharmacy sent him a vial of 40 milliequivalents of concentrated potassium chloride! Well, if you give that to a patient…
Dr. Lobaugh: They're not going to be around for much longer! So knowing what medications are very dangerous I think is important. There's also communication, so a lot of errors all come back to communication lapses. In communication, handwriting used to be a problem, but now it's the electronic medical record. Most of the time when you guys are ordering drugs, you type in the name, right? And it pops up with a variety of options for that drug, but handwriting isn't so much a problem as it was…
Brice: Yeah and in your world too it's even more complicated as far as how to address these errors, because it's unique for you. Because you're the one ordering the medication or you don't even order it. You just, you know, take it out, you're drawing it up, you're actually administering it.
Dr. Lobaugh: So I consider the operating room to be one of the most dangerous places for medication errors, because anesthesiologists are the only providers that go unchecked. So we prescribe, we prepare, we administer, we document, we monitor. All those steps that I described earlier…
Dr. Lobaugh: …are all done by a single person. Maybe there's a resident or a nurse anesthetist involved, but for the most part they're going unchecked. Whereas, if you order a med on the floor, you put in the order and then what happens?
Brice: Yeah, about five different people look at it. There might be an alert that says ‘oh, this is contraindicated.’ You know, all sorts of things.
Dr. Lobaugh: You go through pharmacy, then pharmacy sends it out. Verifies it, sends it out. The nurse
checks it oftentimes. The nurses have a double check. So there's a lot more people involved that can catch an error than during the delivery of anesthesia, so that that's definitely a uniqueness.
Brandon: So why is it that anesthesiologists have all that power with little checks?
Dr. Lobaugh: Because that's the art of anesthesia. I mean you've got to think about when… For example, let's say you have a patient that presents to the ER and their sugar is 300. You're gonna correct that sugar over a long period of time, right? You're gonna admit them, you're gonna get their IV in, you're gonna put the order in, they're gonna send you the insulin, you maybe give them a small dose or start them on infusion and then check periodically. You put that same patient in the OR, you're going to have different… you're going to have different timelines or a different approach. It's much more dynamic. A better example is blood pressure. So you have a patient that comes in with a blood pressure of 200 systolic and 110 diastolic. Let's just throw that one out. So that's an emergent situation, right? And an adult and a kid very emergent, right? So you want to address that, but you don't want to bottom them out, so you're going to give them… if they're eating, maybe give them IV medicine, maybe start him on an oral medicine and kind of watch him over a period of time. For me if I'm in the OR and all sudden that happens in a patient that was previously stable, I'm going to give a medicine that acts over minutes not hours, so it's just very different. I don't have the luxury of the time to go through all those steps. If I had to wait for pharma… so if I have a patient that has that blood pressure and I'm doing an aneurysm clipping and I’m waiting for pharmacy to verify it and then pharmacy to send it and then someone else to check it that patient could…
Brandon: Die. Yeah, so it's about… At that point you're just trying to prioritize, do you want the checks or do you want to be able to get something done in a fast manner?
Dr. Lobaugh: And it's just that it's what the specialty is. So the art of anesthesia is very dynamic you become a specialist in pharmacology and physiology and delivery of these medications. So it is a unique situation.
Brice: Yeah, for sure, for sure.
Dr. Lobaugh: But it's also scary, because if you're going unchecked, you might not know that you did something wrong.
Brice: Yeah and I love what you said before about, you know, we are human as doctors and future doctors. And, you know, we feel sometimes like we have to be perfect, but we're not. We do make mistakes So as anesthesiologists, how do we try to reduce those mistakes?
Dr. Lobaugh: So there have been a lot of focus on safety in the OR and I think that anesthesia providers, anesthesiologists like to tout themselves as champions of patient safety. We have the Anesthesia Patient Safety Foundation and we feel like we were ahead of a lot of other specialties in terms of focusing on this. And I say ‘we,’ I mean people that came way before me and they've looked at things at improving safety. So around medications particularly. So there's labeling. So if you guys step into an OR these days, there are machines that color code and label the drugs. That didn't used to happen. There has been a lot of focus on trying to eliminate look-alike medicines. So epinephrine and ephedrine can look like the same thing in the vial, but they're have very different. They're both going to affect cardiovascular system, but differently, right? And so you want to make sure you try to either separate out medicines that can be look-alike or change the packaging. There's also been focus on the organization. So you guys are going to come into contact with many different doctors. Everyone has a personality, right? Just kind of like if we could go into all of your bedrooms, some of you are clean, some of you are not so clean. Some of you have probably sandwiches and cold pizza slices in your room that I don't even want to know about.
Brice: Right, yeah. Episode of Hoarders maybe.
Brandon: I do have to admit. One, I am not as clean as I thought, as my wife has let me know over the past few months. Two, it's an organized chaos like it's one of those things where she's like ‘Brandon, where is…’ and she'll name something. I'll be like ‘Oh, it's in the second drawer on the left nightstand underneath blah blah blah blah blah. It's right there.’ And she's like ‘what!’ And you find it. Like, it makes sense to me.
Dr. Lobaugh: So I would never want to… if you were an anesthesiologist, I would never want to take over your room from you, because your workspace or your anesthesia workspace where we prepare our drugs is probably not organized. Some people are very particular and I… there's been focus on that, whether we should make that mandatory. Seattle Children's is focused on that and having a standardized drug tray, but meaning your emergency drugs go in the right top hand corner. Your antibiotics go in the bottom , you know, right square and they have it all marked out. And the thought is… does that eliminate error? Because let's say you have a very important meeting. You're my colleague, I need to give you a break so you can go to your meeting, which happens routinely in anesthesia because of the way it works in the operating room. And so I'm giving you a break for your meeting. You've already started the case. It's an important case. If I walk in there and you've got syringes places and it's not organized and tidy and let's say the patient goes into cardiac arrest, I'm going to grab what's familiar, right? I'm going to turn around and feel like I should be able to grab x drug from this spot. Well, if you're not organized or sloppy or messy or whatever you've done… or haven't labeled things correctly, I'm gonna grab something. Let's say you had… feel like the kid… they're having ischemia. And you're kind of stretching my knowledge, because I haven't taken care of an adult in a very long time… But let's say they have ischemia and you want to give them a narcotic and I reach and grab that narcotic and I’m like oh great it should be 10 mics per… I'm just making up a dose, because that's a pediatric dose. But I push it all, but really that was a hundred per. But you didn't label it - that's a problem, right?
Brandon: Oh, yeah absolutely and I am 100% there with you. Like I think there's like pros and cons to the whole thing. Like that's a massive probe, being able to have it standardized and be able to say no matter who walks into the room that x is where x is supposed to be. Y is supposed to be where y is supposed to be. I also know and this is probably a reason why I won't end up being an anesthesiologist, I know that that it's hard for me to maintain like that kind of level organization at all times. Not saying I'm not organized in my own way. It's just my brain doesn't always work that way, so I'm one of those people that
I’m always customizing things the way that makes sense in my head and you're right that would make it extremely difficult for someone to come in…
Dr. Lobaugh: and hand off.
Brandon: And yeah for me to hand off what I’m doing to someone else to go handle another thing. So maybe anesthesia is not for me, but what you're saying is definitely making sense - the fact that like if we have something standard like that it makes it a lot easier to know what's going on and to prevent errors in the operating room or wherever you might be.