Quality Improvement And Patient Safety
Introduction to PHELO for MCCQE1
Quality Improvement (QI) and Patient Safety are fundamental components of the Population Health, Ethical, Legal, and Organizational Aspects of Medicine (PHELO) category in the MCCQE1. Under the CanMEDS framework, these topics heavily involve the roles of Leader (contributing to a culture of safety and improvement) and Health Advocate (ensuring patient well-being through systemic checks).
For the purpose of MCCQE1 preparation, candidates must understand the shift from a “blame culture” to a “just culture”, master the principles of error disclosure, and be familiar with Canadian frameworks for analyzing adverse events.
CanMEDS Context: As a Leader, a physician contributes to the improvement of health care delivery in teams, organizations, and systems. You must demonstrate the ability to analyze patient safety incidents to enhance systems of care.
Patient Safety: Core Concepts
Patient safety is the prevention of errors and adverse effects to patients associated with health care.
The Swiss Cheese Model
Proposed by James Reason, this model is the standard for understanding medical errors in Canadian healthcare. It posits that errors are rarely the fault of a single individual but rather a sequence of system failures.
- Slices of Cheese: Represent barriers or safeguards (e.g., protocols, alarms, double-checks).
- Holes: Represent failures (latent or active).
- Accident: Occurs when the holes in all slices align, allowing a hazard to reach the patient.
Taxonomy of Errors
Understanding the type of error is crucial for the MCCQE1 to determine the appropriate intervention.
| Error Type | Definition | Example |
|---|---|---|
| Slip | Action not as planned (attention failure). | Pushing the wrong button on an infusion pump despite knowing the correct one. |
| Lapse | Memory failure (omission). | Forgetting to order a routine potassium check for a patient on Lasix. |
| Mistake | Plan was wrong (knowledge/rule-based failure). | Prescribing an antibiotic to which the patient is allergic because the physician didn’t check the allergy list. |
| Violation | Deliberate deviation from protocol. | Intentionally skipping a “Time Out” before surgery to save time. |
Active vs. Latent Failures
- Active Failures: Unsafe acts committed by people in direct contact with the patient (e.g., giving the wrong drug). These are the “sharp end” of the stick.
- Latent Conditions: Systemic flaws (e.g., understaffing, poor equipment design, fatigue). These are the “blunt end” and are often the root cause of active failures.
Disclosure of Adverse Events
The Canadian Medical Protective Association (CMPA) and the College of Physicians and Surgeons in various provinces mandate the disclosure of harmful patient safety incidents.
High-Yield MCCQE1 Concept
Hiding an error is a professional misconduct. You must disclose harmful incidents to the patient. If the error reached the patient but caused no harm (near miss), disclosure is generally discretionary but encouraged for transparency.
Step 1: Attend to the Patient
The immediate priority is the clinical care of the patient to mitigate further harm.
Step 2: Plan the Disclosure
Gather the facts. Determine who should be present (usually the most responsible physician and a support person for the patient).
Step 3: The Disclosure Discussion
Conduct the meeting as soon as reasonably possible.
- Acknowledge: State clearly what happened.
- Apologize: Use the words “I am sorry.” In Canada, an apology is generally not an admission of legal liability (Apology Acts exist in most provinces), but check local provincial laws.
- Explain: Explain why it happened (if known) without speculating.
- Next Steps: Explain what will be done to prevent recurrence.
Step 4: Documentation
Document the facts of the incident and the content of the disclosure discussion in the medical record.
Quality Improvement (QI) Frameworks
QI involves systematic activities that are organized and implemented to monitor, assess, and improve the quality of health care.
The Donabedian Model
This is a classic framework used to categorize quality measures.
Structure
Structure refers to the attributes of the setting in which care occurs.
- Examples: Nurse-to-patient ratios, availability of MRI machines, percentage of board-certified physicians, electronic health record systems.
The Model for Improvement (PDSA Cycle)
The most common tool for testing change in a clinical setting.
- Plan: Define the objective and predict the outcome.
- Do: Execute the plan (usually on a small scale).
- Study: Analyze the data and compare to predictions.
- Act: Decided to Adopt, Adapt, or Abandon the change.
Root Cause Analysis (RCA) vs. FMEA
| Feature | Root Cause Analysis (RCA) | Failure Mode and Effects Analysis (FMEA) |
|---|---|---|
| Timing | Retrospective (After an event) | Prospective (Before an event) |
| Goal | Identify why an error occurred to prevent recurrence. | Identify potential failures in a new process to prevent them from happening. |
| Key Question | ”Why did this happen?" | "What could go wrong?” |
Canadian Guidelines and Organizations
For MCCQE1 preparation, familiarity with these entities is essential.
Healthcare Excellence Canada (HEC)
Formed by the amalgamation of the Canadian Patient Safety Institute (CPSI) and the Canadian Foundation for Healthcare Improvement (CFHI). They provide national leadership on patient safety.
Institute for Safe Medication Practices Canada (ISMP Canada)
An independent non-profit agency that analyzes medication errors.
”Do Not Use” Abbreviations
ISMP Canada and Accreditation Canada maintain a list of abbreviations that should never be used due to high risk of misinterpretation.
Do NOT Use:
- U, u (unit) -> Write "unit"
- IU (International Unit) -> Write "International Unit"
- Q.D., QD, q.d., qd -> Write "daily"
- Q.O.D., QOD -> Write "every other day"
- Trailing zero (X.0 mg) -> Write "X mg"
- Lack of leading zero (.X mg) -> Write "0.X mg"
- MS, MSO4, MgSO4 -> Write "morphine sulfate" or "magnesium sulfate"Accreditation Canada
Sets Required Organizational Practices (ROPs) that hospitals must follow to maintain accreditation.
- Example ROPs: Medication reconciliation (MedRec) at admission and discharge, surgical safety checklist, suicide risk assessment.
Key Points to Remember for MCCQE1
High-Yield Review
- Just Culture: Focus on system improvement rather than individual punishment, unless there is gross negligence or sabotage.
- Medication Reconciliation (MedRec): The process of creating the most accurate list possible of all medications a patient is taking. Must be done at every transition of care (Admission, Transfer, Discharge).
- SBAR: A standard communication tool for patient safety (Situation, Background, Assessment, Recommendation).
- Never Events: Incidents that should never happen (e.g., surgery on the wrong body part). These usually require mandatory reporting and immediate RCA.
- Second Victim: The healthcare provider involved in an unanticipated adverse patient event who becomes traumatized by the event. Support for the provider is part of the safety culture.
Sample Question
Clinical Scenario
A 62-year-old male is admitted to the internal medicine ward for management of community-acquired pneumonia. The attending physician intends to prescribe Ceftriaxone 1 g IV daily. However, due to a selection error in the electronic order entry system, the physician accidentally selects “Ceftazidime.” The pharmacist verifies the order, and the nurse administers the Ceftazidime. Two hours later, the physician realizes the error. The patient is stable, has no known allergies, and has suffered no adverse reaction, although Ceftazidime is not the optimal coverage for his condition.
Question
Which one of the following is the most appropriate initial action regarding this incident?
- A. Discontinue the Ceftazidime, order Ceftriaxone, and document the change without mentioning the error to the patient to avoid unnecessary anxiety.
- B. Reprimand the nurse and pharmacist for failing to catch the medication error before administration.
- C. Disclose the error to the patient, explain the potential consequences, apologize, and document the discussion in the chart.
- D. Report the incident anonymously to the hospital’s safety reporting system but do not document it in the patient’s chart.
- E. Wait to see if the patient develops any side effects from the Ceftazidime before deciding whether to inform him.
Explanation
The correct answer is:
- C. Disclose the error to the patient, explain the potential consequences, apologize, and document the discussion in the chart.
Detailed Explanation: This scenario represents a medication error that reached the patient. Even though no immediate physical harm occurred, Canadian ethical guidelines (and CMPA recommendations) emphasize transparency.
- C is correct: The physician must disclose the error to the patient. The disclosure should include what happened, why it happened (if known), an apology, and what will be done to remedy the situation (switching to the correct antibiotic). This must be documented.
- A is incorrect: Hiding an error violates professional and ethical standards.
- B is incorrect: This represents a “blame culture.” The error originated with the physician’s entry; while the pharmacist and nurse are part of the “Swiss Cheese” layers that failed, the immediate priority is patient transparency, not punishment. Furthermore, strict reprimands discourage future reporting.
- D is incorrect: While reporting to the safety system is part of Quality Improvement, it does not replace the obligation to disclose to the patient and document the clinical reality in the chart.
- E is incorrect: Disclosure should be prompt and not contingent on the development of harm.
References
- The Royal College of Physicians and Surgeons of Canada. (2015). CanMEDS 2015 Physician Competency Framework. Ottawa, ON.
- Canadian Medical Protective Association (CMPA). (n.d.). Disclosing harm from healthcare delivery: Open and honest communication with patients. Retrieved from CMPA-ACPM.ca .
- Healthcare Excellence Canada. (n.d.). Patient Safety Essentials. Retrieved from HealthcareExcellence.ca .
- Institute for Safe Medication Practices Canada (ISMP Canada). List of Error-Prone Abbreviations, Symbols, and Dose Designations.
- Toronto Notes 2024. Ethical, Legal, and Organizational Medicine. Toronto, ON: Toronto Notes for Medical Students, Inc.