Patient Safety Consult Service

Instructors Guide - Background

John Gosbee, MD, MS

National Center for Patient Safety Department of Veterans Affairs

734-930-5893 <John.Gosbee@med.va.gov>
[www.patientsafety.gov](http://www.patientsafety.gov/)

**Background:**

1)  The concept addresses the advice and critique offered by many
    patient safety and residency curriculum experts: make it real,
    clinical (case-based), and project-based

2)  There is near unanimous support from VA and UM patient safety
    physicians, nurses, and other personnel (July 8^th^ meeting at OAA,
    other conversations with S. Saint, E. Young)

3)  It supports ACGME core competencies and patient safety goals at VA
    and university affiliates.

**Goals:**

1)  Establish a safety culture mindset into medical residents through
    practical safety activities

2)  Build a multi-specialty group of faculty and residents to help
    accomplish Goal #1

**Objectives:**

1)  Resident becomes familiar with the complexity of patient safety

2)  Resident gains knowledge and skills at "diagnosing and treating"
    patient safety issues in an operational, "sharp-end" environment

3)  Resident acquires teaching (persuasion) skills to provide patient
    safety knowledge to medical students, other residents, and faculty

**Short Description:**

1)  Month long elective rotation for one or more residents (there would
    be other patient safety activities and learning sessions (e.g.,
    Raj's case conferences, projects at VA NCPS)

2)  Attending would be John Gosbee (initially); and later Raj, Sanjay,
    Jack Billi, etc?

3)  Consult would be prompted by close calls detected or vulnerabilities
    identified

4)  Attending and resident give "in-service" during rounds with IM,
    surgery, pediatrics, etc

5)  Resident(s) on consult service would be paged/contacted, and they
    contact the attending

6)  \"Issue\" would be \"worked up\", and consultant service note
    (report) would go back to the requesting service within one working
    day (not on the chart)

7)  Preceptor and resident(s) would work through appropriate interfaces
    with safety, quality, etc within the VA or Univ; and safety/quality
    personnel would be involved as much as they wanted

**Examples of Consults**

1)  Resident looks up a X-ray image on the new "filmless" system, and
    realizes the labeling computer screen makes it easier to be reading
    the X-ray on the wrong patient

2)  Attending notices non-invasive blood pressure (NIBP) tubing on many
    ICU patients have a new warning label added by nursing that says,
    "Not IV tubing, For NIBP Use Only".

3)  During morning rounds, patient mentions he was almost transferred to
    a new room, but wasn't after transport person realized he was
    confused with another patient with a similar last name.

4)  Resident starting Internal Medicine rotation notices patient's
    weight is not listed on all the charts, while dosing an
    aminoglycicide; but it was always on the charts during Peds rotation

5)  Radiology resident overhears MRI tech talking about a "flying pen"
    that just missed her head. Curious, he questions the technician, who
    talks about other close calls in the past year.

**Successful Patient Safety Curriculum Pilots - Somewhat Related:**

1)  Anne Tomolo at *Cleveland VAMC* assigned residents on two-week
    urgent care rotation to keep 3x5 card on "interesting" subset of
    patients. When they returned weeks later, residents had to follow-up
    actual patient outcome, analyze any systems issues, and suggest
    fixes.

2)  Raj Mangrulkar (*IM at UM*) assigned residents patient safety
    "homework" in April 2003. (These arose from quality projects and
    RCAs at Ann Arbor VA?) Preliminary findings were very positive, with
    "work-ups" being used by the organization.

3)  Medical and nursing students given real adverse events to work up
    and develop safety remedies for 2-6 week project at *University of
    Minnesota*. Findings presented to safety managers from local
    hospitals  they liked the plans so well, they wanted to implement
    them

**Issues Raised**

1)  Balancing service versus teaching (e.g., ad hoc assignments versus
    set "homework")

2)  Duplication of other efforts (e.g., patient safety rounds at Univ
    Mich)

3)  Sustainability and management after a successful pilot (IM versus
    "general" elective)

4)  What is the most basic approval that we need to proceed with a pilot
    (sign-off list)

**Next Steps:**

1)  Goals and objectives to Raj Mangrulkar for review and internal
    presentation

2)  Meeting with administrative-clinical governance at UM and Ann Arbor
    VAMC

3)  Meetings with other possible supporters:

    a.  Larry Gruppen for Interested Faculty

    b.  GME release person for sign off

    c.  CMS person (Stephen Jencks?) for pilot testing "reimbursement"