medication errors
Illegible orders and transcribing errors are preventable causes of medication errors. In this case, the medication error could be due to an unclear decimal point or a transcription error. Although the increased use of computerized physician order entry systems with drop-down menus for drug, dose, route, and frequency has reduced the incidence of these errors, the systems are not universally available. Physicians must write or enter orders clearly and specifically avoid using trailing zeros to prevent errors in dosage. Studies show that educational interventions to reduce the use of certain abbreviations (eg, QD, μg) and avoid trailing zeros lead to a significant decrease in transcription errors.
Because a particular medication may be available in different dosages, computerized checks with automated alerts may not consistently identify a higher dosage as an error. Computerized systems are helpful in eliminating illegible orders; identifying patients at high risk for an adverse event; and alerting physicians to medication allergies, drug interactions, and dosage limits.
Medication nonadherence
The best initial approach to medication nonadherence is to acknowledge the difficulty of taking a medication daily.
nonjudgmental
Physicians must assess the patient’s understanding and provide targeted education to address misconceptions.
Physicians should use a nonjudgmental, patient-centered approach in discussing treatment nonadherence. Acknowledging the difficulty of taking medication regularly can strengthen the therapeutic alliance, potentially improving patient receptiveness to educational efforts.
Medication nonadherence
Risk factors
Complex treatment regimen
Adverse drug effects
Expensive drug regimen/limited patient financial resources
Little immediate or apparent benefit of medication
Inadequate physician supervision & written instruction
Interventions to improve adherence
Integration into daily habits/schedule
Pill organizers & dispensers
Simplified treatment regimen
Automated reminders (eg, smartphone applications)
Frequent telephone contacts & interprofessional (eg, nurse, pharmacist) follow-up
Motivational interviewing
Consolidated refill schedule
gift
It is ethically problematic for physicians to accept expensive gifts as they may influence or appear to influence professional judgment. These gifts should be declined after expressing appreciation for the gesture.
Accepting low monetary value gifts is not unethical, and the physician should accept the cookies and thank-you card to be sensitive to the patient’s feelings.
sex history
When asking about sexual partners, the physician should avoid using labels or making assumptions about patients or their partners’ sexual orientation or gender identity. Asking an open-ended question about all sexual partners allows patients to describe their sexual partners and behavior in terms that they are familiar with and that reflect their gender identity. After inquiring about the gender of sexual partners (including trans, nonbinary), the physician can ask about pertinent types of sex (eg, vaginal, oral, anal) with each partner in order to make testing recommendations for sexually transmitted infections (eg, HIV) and discuss risk-reduction strategies. Another possible formulation is, “What is/are the sex and gender of your sexual partner(s)?”
adolescent visits
In situations in which a parent’s presence may interfere with obtaining honest answers from an adolescent patient, physicians should politely ask the parent to wait outside and interview the patient privately.
All adolescent visits should include an opportunity to interview the patient alone to discuss topics such as drugs, alcohol, tobacco, and sexual activity.
angry patient
When confronting an angry patient, the physician should use a nondefensive, empathic approach that acknowledges the patient’s anger and attempts to explore the patient’s underlying concerns.
elicits the patient’s understanding about his condition and encourages him to express his concerns and fears about the diagnosis that likely underlie his behavior.
agitated patients
In agitated patients, especially those admitted for self-inflicted injuries or recent violence, the potential for further violence should be addressed directly. Patients should be asked if they are having any thoughts or impulses to hurt themselves or others.
history
Review of medications to determine if any are unnecessary or causing adverse effects is essential in providing high-quality patient care.
The cumulative anticholinergic burden of multiple medications is especially problematic in the elderly.
Communicating with deaf
Communicating with deaf & hard of hearing patients
Modes of communication:
1.Interpreter (or provider) fluent in medical communication & American Sign Language
2.Alternate modes:
-Computer-assisted real-time transcription
-Assistive listening devices
-Lip reading*
-Family/friends*
-Written communication*
- Not recommended unless preferred by the patient.
Supplemental measures:
-Printed information sheets
-Captioned videos
provider refuses to provide care
Conscientious refusal of treatment occurs when a provider refuses to provide care due to moral conflict.
Providers who cannot, in good conscience, provide treatment that a patient requests, are obligated to refer the patient in a timely fashion to another provider who can. This respects the patient’s autonomy.
Approach to treatment refusal
1.Determine legal decision-maker
Self: legal/competent adult or emancipated minor
Surrogate decision-maker: parent/guardian, specified proxy, default surrogate (eg, spouse, adult child)
2.Counsel decision-maker
Assess level of understanding, health literacy
Explain natural history of disease, pros & cons of treatment options VERY IMPORTANTT
3.Continued refusal
-For life-sustaining treatment:
Engage care team, social services
Consult facility ethics committee
Initiate legal action for court order
-If immediate care is needed (eg, life- or limb-threatening condition):
Provider should administer care over surrogate refusal
Risk of wrong-site surgery
Risk of wrong-site surgery can be reduced by requiring “dual identifiers” (usually a nurse and physician) to independently confirm that they have the correct patient, site, and procedure. Checks must be truly independent to ensure patient safety.
Elements of informed consent
1.Preconditions
Competency
Voluntariness
2.Disclosure of key facts
Diagnosis
Proposed treatment or procedure
Alternate treatment options (medical, surgical)
Risks/benefits of proposed treatment & alternatives
Common complications
Rare but major complications
Risks of refusing treatment
3.Other disclosures if applicable
Role of residents & medical students
Anticipated additional procedures
Financial conflicts
NOTE :Patients have the right to withdraw consent at any time. When patients change their minds and refuse treatment, it is the physician’s responsibility to engage them in a new discussion of informed consent or informed refusal.
Overutilization
1.Definition
Services (tests or treatments) that:
Are not reasonably expected to benefit the patient
Are not necessary for clinical decision-making
2.Strategies to reduce overutilization
Determine how a test will affect management before ordering
Use evidence-based practice guidelines that emphasize services with proven benefit
Avoid redundant tests & treatment
Error disclosure to patients
IMPORTANT
1.Describe the error
“Unfortunately, the biopsy sample was lost, and a repeat procedure is necessary.”
2.Explain why the error occurred
“The laboratory never received the sample, possibly due to a tracking or staffing error.”
3.Express regret or apologize for error
“I apologize on behalf of our team.”
4.Describe steps to minimize consequences
“We will waive all charges associated with the repeat procedure.”
5.Outline actions to prevent future recurrences
“I will notify our administrators now of this error, and we will change our procedure so this does not happen again.”
report impaired colleagues
in a timely manner
This can usually be done anonymously
- The colleague’s immediate supervisor should be informed so that the situation can be dealt with as quickly as possible.
2.In a non-emergency situation, a person should contact the designated hospital committee, commonly called a physician health program
3.If this is not possible or such a body does not exist, then the state licensing board should be contacted.
Motivational interviewing
Indications
Substance use disorders
Other behaviors in patients who are not ready to
change Principles
Acknowledge resistance to change
Address discrepancies between behavior & long-term goals
Enhance motivation to change
Nonjudgmental
Technique (OARS)
Ask Open-ended questions (encourage further discussion)
Give Affirmations
Reflect & Summarize main points
TIME
Outpatient office schedules are typically arranged in regular time intervals (eg, 15-20 min) corresponding to the time needed for an average patient visit. Typically, the time interval allows the physician to evaluate one primary objective, either evaluating a new problem or following up on well-known chronic conditions.
When a patient raises an unexpected concern during an office appointment and adequate time has not been allotted to evaluate it, the physician should generally ask the patient to schedule an appointment at a later date to address that concern.
NOTE :when the unexpected concern is urgent or likely serious (eg, shortness of breath), it should be addressed immediately, and subsequent patients should be informed of the delay.
patient-centered approach
patient-centered approach that
1.validates the patient’s concerns,
2.educates the patient about the adverse effects of antibiotics and their lack of efficacy in treating viral infections, and3.
provides options to treat the patient symptomatically.
This must be done in an empathic and nonjudgmental fashion
complementary medicine
When discussing complementary and alternative medical interventions, the physician should be honest, helpful, and nonjudgmental, developing a trusting physician-patient relationship conducive to sharing evidence-based information. Physicians should obtain more information on unfamiliar products and follow up with the patient or direct the patient to reliable information sources.
DIICLOSURE CASE
After a patient’s death, disclosure of pertinent medical history (including psychiatric history) is permitted to a personal representative (eg, spouse, parent) under the Health Insurance Portability and Accountability Act (HIPAA)
partner violence
Assessment of intimate partner violence
Signs
Location of injuries (eg, genitals, torso, face, head, neck)
Inconsistent explanation, evasive, fearful
Nonadherence to follow-up, emergency department visits
Partner who resists patient being seen alone
Discomfort in examination, sexually transmitted infections, chronic pelvic pain
Interview strategies
1.Ensure privacy
2.VERY IMPORTANT :Nonjudgmental, empathic, open-ended questions
3.Avoid pressuring to disclose abuse or report or leave partner
4.Assess immediate safety; determine emergency safety plan, provide referrals for resources as needed (eg, shelters, domestic violence agency, mental health)
partner violence
Intimate partner violence
Evaluation
Routine annual examination
Suspicious signs/symptoms (eg, bruising)
Prenatal visits
Consequences
Homicide
Mental health disorders (eg, PTSD)
Unintended pregnancy
Pregnancy complications (eg, abruptio placentae)
Sexually transmitted infections
Management
Safety planning (eg, local shelter referral)
Psychosocial counseling
