Dermatology World July 2011 SUPPLEMENT : Page 16
Not to Err DErmatology-spEcific safEty issuEs: thE biopsy Literature collected by the American Academy of Dermatology’s Performance Measurement Task Force suggests that gaps in dermatologic care occur more often with surgeries and biopsies. This realization triggered the development of a biopsy follow-up process measure, which was submitted for inclusion in the Medicare’s Physician Quality Reporting System (PQRS) in 2012. “There are many steps involved in the labeling, transmittal, processing, and reporting of those biopsies,” said Dr. Elston, who chairs the Academy’s task force. Finding the site of a recent biopsy can be a problem in dermatology practices. Dermatologists, according to Dr. Elston, are very adept at doing biopsies that don’t leave undue scars — so good, in fact, that biopsy sites may be hard to find when patients return for surgery. “On the other hand, the patient may have many scars from prior procedures, and the biopsy site gets lost in a sea of scars. In either case, which is the recent biopsy?” he said. Pre-procedure photographs and diagrams have been cited as the best ways to accurately identify biopsy sites. Another common error is the mislabeling of specimens. In a typical scenario a dermatologist may perform three biopsies (a, b, and c) on a patient, on the same day. Biopsy b is almost always in the right bottle but a and c might be switched, because of errors in communication between the dermatologist and the assistant. “For the patient, it can make a big difference whether the melanoma is in bottle a or c,” Dr. Elston said. “There are all sorts of variations on that scenario.” Following the universal protocol of the Joint Commission should help avoid biopsy mislabeling, according to James S. Taylor, M.D., consultant dermatologist and the quality improvement officer for the Dermatology and Plastic Surgery Institute at Ohio’s Cleveland Clinic. “It’s where, before you finish the procedure, you double check that the specimens are labeled correctly, with the correct patient’s name, biopsy site, and differential diagnosis,” he said. The next step is the follow-up. If, for example, a report comes back as malignant melanoma, there’s the issue of timely reporting to the patient. Do you send a letter? A letter could be lost in the mail. It’s critical, according to Dr. Taylor, that the dermatologist or staff records the pathology or laboratory results in the patient’s chart and documents when and how the patient is notified. “For skin cancers I recommend both written and verbal communication with the patient,” he said. “The important thing is to make sure that you tell patients that they will hear from you one way or another, and, if they haven’t, they should call your office,” Dr. Taylor said. The AAD’s Performance Measurement Task Force has been identifying gaps in care through its participation in PQRS. The National Quality Forum, a voluntary consensus standards body that reviews and endorses quality measures, has endorsed four measures relevant to dermatologists: Melanoma Coordination of Care; Over Utilization of Imaging Studies in Stage 0-IA Melanoma; Melanoma Continuity of Care – Recall System; and Biopsy Follow-up. Dermatologists can currently report on the three melanoma measures in the 2011 PQRS program. The Biopsy Follow-up measure is tentatively slated for inclusion 16 supplement to dermatology World // July 2011 in the 2012 PQRS program. See www.aad.org/education-and-quality-care/performance-measurement-and-quality-reporting for more information on measures and the Medicare quality program. surgical pitfalls Dermatologists can avoid fire hazards, electrical shock, and more with such safe practices as electrical equipment grounding. “We use electrocautery; so, proper grounding of all the electrical equipment (lights, sockets, everything in the room where the surgery is being done) is important,” said Dr. Elston, who was lead author on a continuing medical education article about patient safety in the August 2009 Journal of the American Academy of Dermatology . The proper use of electrocautery is another area where dermatologists need to be particularly aware of patient safety. Dermatologists need to consider if the patient has a pacemaker or implantable defibrillator, as well as to decide whether to continue anticoagulation for patients. “If you continue the anticoagulation in someone who needs it for medical reasons, the patient may develop a hematoma. If you discontinue it, the patient may have a stroke. So the usual guideline is that if the anticoagulation is needed for a medical reason, it is not discontinued,” Dr. Elston said. Other important safety considerations for surgical cases include sterility and infection control and proper patient positioning. “Most injuries to patients in the office setting from surgery are from the patient fainting and associated falls,” Dr. Elston said. “Proper positioning of the patient during injection of anesthesia is important.” mEDicatioN Errors prEvENtablE The most frequent errors in medicine, in general, relate to medications, according to Dr. Taylor. Dr. Taylor suggests that in order to avoid medication errors, dermatologists should think in terms of the five rights: right drug, right patient, right dose, right route (orally, intramuscularly, or intravenously) and right time. There are many ways to prevent medication errors. One safety net is electronic prescribing, which can be implemented with or without an electronic medical record (EMR), according to Dr. Taylor. Dermatologists can receive government incentives to implement e-prescribing and face penalties beginning next year for failure to do so. See www.aad.org/hitkit for more information. The technology eliminates the problem of handwriting illegibility, because prescriptions are computer-generated and printed. It’s not foolproof, however. “If, for example, you have a drug with three different dosages: 100mg, 200mg, and 300mg, you may need to give the patient 100mg, but highlight 200mg accidentally,” Dr. Taylor said. “You have to proofread the prescription with electronic prescribing. It does not avoid all errors, but, overall, the odds are that it improves prevention of medication errors and expedites processing.” Dermatologists and staff should avoid interruptions when filling a prescription, according to Dr. Taylor. A physician www.aad.org
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