Quality Improvement in Healthcare Episode 3 | 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.
Dr. Lobaugh: Anesthesia definitely draws, I think, the type A I'll say control freaks… some it's a range of that, but yes.
Brice: People who love the container store, maybe?
Dr. Lobaugh: Yeah and for those of you who have yet to come. When you come on to TCH to rotate over and see us, the pediatric anesthesiologists it's even a little bit more intense. Especially when you're dealing with the neonates the small babies, my OCD factor goes through the roof when i have a small baby compared to when I have a 15 year old, per se.
Brice: Yeah, I love these, like, standard standardization solutions you're talking about, because it seems like common sense to me. You know, like, they may not be easy to implement necessarily, but they're pretty simple solutions that I bet would have pretty large effects and really help patient care.
Dr. Lobaugh: Yeah, I think they're…it's somewhat controversial. But there is a talk or a push to standardize a lot of things in medicine. If you're talking about like the ER, how we treat people that come in with sepsis, you know, they fit this algorithm. If they meet x, y, and z, they go down this pathway and I think it's nice to have those checks and balances. It's not taking away the ability of the physician to make clinical decisions, but it's ensuring that there are safety nets to catch those things. Because sometimes you don't go around down the right path. You're starting to look for zebras when it really is just a horse. I don't know if I said that correctly, but…
Brandon: No, you did. Sometimes people would say well what if it's a donkey?
Brandon: But no that's the phrase.
Brice: A giraffe.
Brice: Do you think other specialties could learn lessons from anesthesia in the way that they do things?
Dr. Lobaugh: Umm yes, but I mean again I think anesthesia is so unique. I think that each specialty has to figure out what works for them. Yeah, you know, like the example in the ER. The ER has found tremendous ways to catch those, you know, very severe, acute needs versus something, you know, when you're triaging patients… How do you know who needs attention right now? Versus someone who really can wait several hours if you're swamped. And they've learned those lessons through experience and I think that kind of plays into the culture. I think it's important when you're looking at, you know, these problems, are you assessing performance? Do you have the data? Do you have a way to report problems? Does your department want to know what's wrong? So if your department doesn't really want to know what the problems are that's really hard to fix it, right? So you should have systems for reporting these and be able to evaluate them in a unbiased manner.
Brice: Right and if you feel like you're going to be punished, then no one's going to report.
Dr. Lobaugh: Correct. I mean the problem with I think… So you have quality improvement where you're improving the process, but in general this is safety events and reporting errors, right? And I think the problem with reporting errors is people either don't see that it's a value. Why am I going to take the time to fill out this very long complicated report if nothing ever happens about it? Or they don't want to be stigmatized and I think that it's important to try to diminish that kind of culture of shame and blame, which I think there's been a lot of attention to it. But it still persists.
Brice: Yeah, absolutely. I'm sure it depends on the institution that you're at.
Dr. Lobaugh: Absolutely
Brice: Hopefully you're at a good one.
Dr. Lobaugh: So when you guys start looking at programs, I think programs that, you know… If someone tells you it's malignant, ask why!
Brice: There’s something there.
Dr. Lobaugh: Figure out, you know, what kind of environment… I think at his stage where you guys are at you should have a program that holds you accountable and responsible for someone's life, because that's what you guys are going to be handed. But you also want one that is fair and can look at a problem or error and figure out is it negligence? Do you need to have some kind of remediation? Or is it… If you guys google and I don't know if you guys have had this in any of your QI safety things… like Annie's story, which is about…
Brice: I think I’ve heard that yeah..
Dr. Lobaugh: A nurse in Georgetown that kept checking a patient's blood sugar and it was telling her error, too high. So she kept treating it, because that's what the glucometer was telling her. And the patient ended up critical, having an RT or rapid response and sent to the ICU. And when they checked it in the ICU, it was critically low, not critically high. But she… and she was put on leave and punished and when they actually went back and investigated it, they looked at the human factors of it. And it was the machine that failed her not that she failed the patient.
Dr. Lobaugh: So I think it's important that you find a culture that promotes that.
Brandon: So that's actually something that I was thinking of when you're talking about reporting. And things like that… What generally is the course of action when someone, like, discovers a medical error? Like what… I guess maybe you could talk about, like, what generally happens? And then maybe if you could explain what you think should happen?
Dr. Lobaugh: So I think it depends on the severity. So in anesthesia, the first question I would ask is does
it cause harm. And what level of harm. There are… if you look at a lot of the literature, there are levels of harm. Is it that the error just caused psychological distress? Did you have to give additional treatment but not sustained, temporary harm? So we call temporary harm for let's say an event… cardiac arrest. If you're doing chest compressions, that's the potential for temporary harm, right? Does it cause permanent harm? Did you cause a paresthesia that's persistent? And then there's death. And depending on where you are on that spectrum I think depends on your approach. One of the areas is disclosure. To tell the family, do not tell the family? So I'm all for disclosure…
Brice: It’s usually the best thing to do
Dr. Lobaugh: I think it's very important. Honesty is the best policy. You may not get the answer you want. So I made a medication error when I was a fellow. I did math in my head, which you should not do in pediatrics with a baby. You should always verify and we just… The drug I gave was Toradol, but I gave double the dose. And so the patient was fine. We verified with risk management. I reached out to the pharmacists and talked about the doses. We kept the patient overnight. We checked extra labs. The worst part of it and the most… The baby was fine. The most unsatisfying part was the disclosure. The parents were livid. They were… they did not accept it. They asked to speak to our division chief. They wanted the hospital patient safety officer. The baby was fine and went home and didn't have any sequelae, which I'm very grateful for that. They continued to call the hospital for six months saying what are we going to do about it? And that's a horrible feeling, right? And I think that that has persisted in my mind as a memory that disclosure is important, but it's not really going to be gratifying. You're not going to feel good after you do it. But it doesn't mean that it's not the right thing to do.
Brice: Right, that's amazing. Yeah, you did the right thing but…
Dr. Lobaugh: And I'm grateful that I didn't cause harm, because the psychological effects on me as a young provider, as a trainee if it had caused harm would probably have been much more significant. But thankfully, the baby was okay. But the disclosure wasn't… They were unwilling to accept that.
Brandon: Right and I guess at that point you have to be really glad that you're at an institution that can back you up and that's…
Dr. Lobaugh: Correct
Brandon: We understand that this was an issue, but fortunately we don't have any ill consequences.
Dr. Lobaugh: Absolutely
Brice: Yeah and it's not the individual. Yeah, it's not their fault necessarily. It’s…
Dr. Lobaugh: There are multiple factors that play into that and I mean I've had trainees since then make similar errors and I think that it's very important… and I teach them is that verifying and having an extra safety mechanism to check yourself is very critical. So the anesthesiologist, the resident, whoever's in the room giving the medications to the patient under anesthesia does go unchecked. But there have been things put in place to help that. So one is the electronic medical record. So I tell my trainees, unless it's an emergency, you should always verify the dose that you're going to be giving on the computer. So we have an electronic anesthesia record. You can put in the dose with the patient's weight and make sure that it verifies before you give it. And I think that it's important to do that step, because you can do math in your head sometimes - but not all the time.
Brice: Yeah, just take the extra step
Brandon: Along with that we've talked a lot about different things that hospitals are doing and, of course, in medical training. Do you think there's any value in talking about medication errors and providing education towards the public in general. Like, what's being done in that area?
Dr. Lobaugh: So I think that it's… that is like a huge task.
Dr. Lobaugh: But what you can… To break that down a little bit, it's patient education of medication and medication safety. I think that it's important that you take the time to educate patients and figure out what their competency is. For example, we have a very diverse population at all these hospitals. We're in Houston, Texas, the melting pot of the world, right? There are very different levels of literacy and understanding about medicine, medical care, medications. I think it's very important that when you're sending a patient home with medications, for example, they understand what the steps are. One drug being Tylenol, right? In kids were giving Tylenol a lot for post-operative pain. If patients don't understand or their families. Obviously parents are giving it… don't understand the schedule they can become confused and give the medication too little, too infrequently, having two big of spaces and then the kid’s really uncomfortable or too frequently and then you have a Tylenol overdose and that's not good either, right? And so I think that there is an element of medication safety that you need to look at is the understanding and the ability to recall or give the medication. Because they're actually, they're going home and delivering this medication without your direct supervision, right? So they need to… you need to have faith that they can do it correctly.
Dr. Lobaugh: Because medications, even Tylenol can be not benign, right? Motrin cannot be benign.
Dr. Lobaugh: If used incorrectly.
Brice: It always comes back to communication.
Dr. Lobaugh: Correct
Brice: What do you think clinicians, your everyday general internist or just any clinician - what can they do to help reduce medication errors in their practice?
Dr. Lobaugh: I think they have to look at what their own local environment is like and what are the issues that they have. So one thing that we focused on in anesthesia is high risk medications, so infusions and then some of the medications I talked about. But that might not be applicable to someone who is practicing in rural Texas.
Dr. Lobaugh: Or even in a metropolitan clinic here in Houston. They're going to focus much more on blood pressure medications and knowing the dosages of that and so I think that comes back to culture and the ability to have data and understand what the problem really is. Because if you try to implement the wrong solution or you try to implement a solution that's too big for your local environment, that doesn't work if you don't have the resources. So if you have a tiny clinic and there's, you know, three doctors and two MAs and you're trying to do this big time consuming assessment for every patient to reduce these errors, that's not really going to work. If the internist is supposed to see 30 patients in a day, right? So you have to have the right… You have to identify the right problem and have it be the right environment. You have to make sure you have the tools for success, so that can be leadership. You can make sure you have all the stakeholders, so in that clinic if you don't ask the MAs what their view is, you could have this brilliant idea and then they're like ‘wait a minute that doesn't work with how we do patient flow or patient care’ and it's not going to work.
Dr. Lobaugh: So you have to bring everyone to the table and that's a huge part of implementing and designing these solutions.
Brandon: So does technology play a role in kind of helping that, because you're talking about, like, having all these lengthy, different, like… there's an option where you could sit down and say ‘Okay, well we're going to review every patient today and make sure we did it right,’ but then we were also talking about earlier about Epic… About how, you know, there's lots of stuff that pops up and it's more click to drag versus writing and stuff like that. How do you feel technology comes into helping reduce medical error?
Dr. Lobaugh: So there is technology used as a delivery mechanism. So in my world in anesthesia, we have automated pumps and there are Codonics, like I said is the labeling machine. There is also not out on the market, but there's been talk or the development of a product that has a barcode and measures the… it knows the dose of the medicine you're giving and it measures when it's delivered as a safety mechanism. So there's all these things that help you deliver medication. There is the electronic medical record that's supposed to be helping you prescribe correctly. So when you guys are on the wards now let's say you want to start an insulin infusion. So there's an automated order set that comes up. So that order set was likely developed a long time ago, because people were making significant errors in how they did it and it eliminates the wrong dose or the wrong delivery, the wrong concentration. And it allows all of that to be safety checked in a much more streamlined way in terms of ordering. It also allows for documenting. There's so many technologies. The answer to everything, right? One of my mentors says that every single QI problem is solved by technology and informatics.
Brice: Oh, interesting.
Dr. Lobaugh: So if you are a data person, an informatics person, your ability to affect quality is tremendous. Your potential. So I am actually involved a lot with The Society for Technology in Anesthesia, not because I know anything. I can hardly run an excel sheet, but because I know that my colleagues in that field are what I need to successfully drive quality forward.
Brandon: Gotcha, I'm gonna put that on a plaque. Every issue with QI can be solved by technology and
Dr. Lobaugh: Correct
Brice: I love it. Put it on a throw pillow, yeah.
Brandon: There you go. One of those ones that you can slide up and down
Dr. Lobaugh: I mean even data… So we need to get away from subjective data in medicine and be able to pull from Epic. Pull from these systems discrete data points, so you can learn and it should be an easy… I want to know I had seven patients today. I want to know what were their PACU pain scores on arrival. What were they 15 minutes after arrival. What were they on time of discharge and then I can compare that to all my colleagues. I have 90 colleagues in my department and say so you… And it's not the blame game, but your patients frequently have higher post-operative pain and poor pain control in the recovery room compared to the majority of our providers. What do you think you could do differently? Because how else can I be better? This is the practice of anesthesia, the practice of medicine. You should be able to get feedback of what you can do to improve in a non-punitive way and we all want to be better providers. And by having that feedback, that data allows you to grow, because whether you're five years out of training, 10 years or you're 20 years out the… You know, you still should want to improve. If you think you're done improving, then you should get out of medicine.
Brice: And you would think with the EMR that that would be seamless to get that information, but I know it's not, right?
Dr. Lobaugh: So if you guys come over to TCH, there is an ENT doctor, her name is Carla Giannoni and she is kind of an Epic guru and at TCH. And she loves to say ‘garbage in, garbage out.’ So if you've read a lot of the charts now that you're on the wards, how many times do you see people cut and paste a note? And it's not accurate. It says the patient's 10 years old and you're like ‘well, they're really 12 now,’ has notes from someone that has nothing to do with why they're here today and it can often be misleading. And then people follow what that says.
Brice: Cut and paste that, yeah.
Dr. Lobaugh: Correct
Brice: And there's templates that, you know, say that you did a physical exam thing that you didn't actually do…
Dr. Lobaugh: and so I think that the EMR could definitely be better and I think that it is unfortunate that we are not at a point where Epic can collaborate with other hospitals. I mean my Epic shouldn't be drastically different from the Epic at CHOP or at CHLA or at Denver Kids. They should all be able to function together, so that you can collaborate. So that you can compare and that doesn't really exist, right?
Brandon: Yeah, well I mean that's terrifying, because, you know, some people out there think that once you can centralize that information, then you know, you can be tracked and recorded and all that stuff and we… I don't know if we're ready as a society yet to allow that to happen.
Dr. Lobaugh: So protecting patient information is very important, but you also need to have systems. So if you went and sought care let's say at St. Luke's and had a surgery where you had a difficult airway and you had to be fiber optically intubated. And then you show up let's say at Ben Taub after a horrible car accident. And I'm on call and I have to come down. If I pull up your record and I don't have access to that, I'm going to go in and, you know, I got to treat your airway. It would be better if I knew that before I start to address your airway, right? Because I could have called for all of those things. You know, same thing. Let's say you have a terrible adverse reaction to… I don't know what drugs…
Dr. Lobaugh: You have anaphylaxis. Well if you were cared for at, you know, x hospital and it's all over the chart there, but now you're showing up in my hospital emergency, it'd be nice to know that, right? Because you may not have family with you. I may not know that, right? So that's where I think collaboration of data and streamlining data would be helpful.
Brice: Yeah, again it's kind of a simple common sense solution, but you need those stakeholders and everyone to be on board and recognize that it's an issue.
Brandon: And education so the general public understands that you're not trying to harvest every last detail about them.
Dr. Lobaugh: You also need Epic to be a little bit more sharing, yeah.
Brice: I guess it's a private company, so, yeah, they can do whatever they want.
Dr. Lobaugh: Correct, it's like Apple.
Brice: Yeah, kind of on that topic. I was curious about this… Is there, like, a safety score for hospitals or for physicians? Is that something that's coming on the horizon?
Dr. Lobaugh: I think it's probably definitely coming. So with CMS and Medicaid, Medicare. There is scoring. There is a lot of the outcomes disclosed particularly in the adult world. The kids world is not as up-to-date, but that is a blessing and a curse, right? Because how is that scoring decided? So you guys will start to hear a lot of this. So if your score is based on satisfaction, patient satisfaction. What does that satisfaction mean? Does it mean that you gave a bad score because every day the resident woke you up at six am to do your vitals when you were in the ICU? Is that really fair?
Brandon: No way
Dr. Lobaugh: I mean you can try to be nice and quiet at 6am, but the way a hospital works it's important for you to get those vitals so that then when you're rounding as a team you can address the problems, you can get the consults, and you can start the medication so that it's not 4pm and the patient still hasn't had those needs addressed. So that's why you get woken up at 6am for those things, right? The patient doesn't necessarily understand that.
Dr. Lobaugh: The same… Let's say you come in for a terrible car accident. You're angry, you know, you've lost a limb. You got a car accident, you know, whatever the circumstances are. Do you think you're going to say that you had a good experience, right?
Brandon: Probably not.
Dr. Lobaugh: Probably not. Yeah, so that's not necessarily fair. If you Brandon Garcia, the ER doctor have done everything possible and saved this kid's life, if they're like ‘no, dissatisfied.’ So that's one of the fears about the scores, and I think that you just have to be careful in how you go forward with that.
Brice: Yeah, hospitals are not set up to, you know, provide guest satisfaction as we...
Brandon: Well, we're not hotels.
Brice: Yeah, I used to be in the hotel business. It’s all about guest satisfaction.
Dr. Lobaugh: You know that there's a lot of consulting like TCH has Disney Consulting, so it is about the patient experience and you want to make patients feel like their needs are met, like their voice is heard, like they're part of the decision and the process. But there are some things that are out of your hands and a factor of health care. I will say the one thing that scores have done. Particularly in adult setting, you know, they focused on scores with, for example, heart surgeries that came out… I don't even remember the date of that and it showed that maybe you shouldn't be getting your triple bypass surgery at a hospital that does a lower number of these cases compared to a hospital that does greater than 5000 cases. You know, I’m making up those numbers, because I don't recall the actual numbers. But I think that that is one thing that has been looked at… should hospitals that don't meet a threshold of a particular type of surgery, a particular type of procedure or service line be allowed to perform those and I think that's a good question to ask. I mean if you're shopping around for a hospital to have your transplant surgery, are you gonna go to one that does a couple kidney transplants a year? Are you gonna go to one that's, you know, outperforming and having really good quality outcomes doing 50-60 kidney transplants a year?
Brice: Yeah, does the patient have the right to know, you know, how good their doctor is? I would say ‘probably.’
Dr. Lobaugh: So that's where I think scoring is a definitely tool that can be used in a positive way.
Brice: Awesome, well I think we've learned a lot here. Is there anything else you would like to share about your work?
Dr. Lobaugh: You know, I think that the thing that I reiterate is you can get involved in QI a little bit or a whole lot. You don't have to dive in like I've got myself so entrenched in this. You can just have a problem and propose a solution and go with it. And I think you can take on a small project, whether you're in internal medicine or radiology or ER and contribute in that way. And I think that with some basic understanding of the steps and tools you can succeed. Or if you want to run a hospital one day I think that more power to you. I would say definitely try to get the training and experience, but physician leadership is so important in how hospitals are run in my opinion. I think we need more people involved in setting the priorities and determining what are the goals and priorities of a hospital.
Brice: How do students and residents get involved in that kind of thing? Patient safety and leadership in the hospital?
Dr. Lobaugh: I think that, you know, you have to be eager. You have to pursue sometimes in a nagging capacity. You know, start out with the basic courses. There's a lot of I think younger junior faculty, you know, Molly like I said. I use her as an example Horstman at the VA, myself. And ask for opportunities. It's depending on what's going on, that can be very challenging for us to find opportunities out of nowhere, but if you're persistent I think that you can get experiences. And just you're not going to have a groundbreaking, you know, published study coming necessarily out of medical school, but you could get your feet wet. Get a little bit of experience and then when you're in residency say, ‘Hey, you know, could I do this project when I'm on this rotation?’ And, you know, ‘How do you think I can be supported in that?’ Get involved in that and then it grows from there. So I think persistence is probably the biggest thing.
Brandon: There you go. Persistence. I used to always get told persistence beats resistance, so I love it when people talk about that.
Brice: That’s what it's all about. Do you have anything else?
Brandon: No, I'm just really glad you were able to come and chat with us today I feel like I've personally learned a lot, so again I'm just super glad you're willing to come onto the podcast and chat with us for a little bit. I can't wait to get this out, so other people can hear some of the things you have to talk about.
Dr. Lobaugh: Thanks for having me, I'm just glad I didn't have this baby before.
Brice: I know it really worked out.
Brandon: When are you due if you don't mind me asking?
Dr. Lobaugh: So I'm not due till the end of July but I'm actually out of the OR right now, because the baby is trying to come too early. So if you…I was telling Brice the students that were in my Intro class a couple years ago, I had just had my son, my first son and I was like… had all the lectures lined up and I was gonna teach on, I think some date in June… kind of around this time. I was like, it doesn't matter the baby's not gonna be due for several more weeks, I’ll be fine. And then my son came five weeks early, so history is repeating itself with the second boy.
Brandon: Eager to get here.
Dr. Lobaugh: Boys
Brice: Hopefully you have some good OB colleagues to get you through.
Dr. Lobaugh: Yes, being at Texas Children's is a very good place
Brice: For sure.
Brandon: All right, well thank you so much and if that is all I’m gonna hit the stop button.