Wait, I know what you’re thinking, boring, dry, and don’t scold me. I am not going to do any of that today, and instead am going to tell you how to easily improve patient care, save money, and improve staff morale.
The easiest things to do to improve safety in the office include better communications, infection control, correct patient/site identification, dealing with emergencies, and staff safety.
Staff communication is often surprisingly poor, and physicians often assume staff can read our minds (and if they have worked for you for many years, maybe they can!). Always make sure staff – and patients – repeat back complicated instructions (better to start by making them less complicated). Never assume your patients are literate, 14% of adults cannot read, so make sure your staff goes over printed materials with the patients.
Something easy you can do is eliminate abbreviations from your prescription pad and your medical record.
Failure to follow up on path reports and lost biopsies is a frequent cause for lawsuits. You need to make sure you have a redundant system for tracking and reporting pathology results. In addition to the old reliable pathology log book, you need a sequential system ensuring that the specimen made it to the lab, that the result was generated and received, that the patient was notified, and that further action was taken if needed. If this is integrated into your electronic medical record, so much the better, but you still need a paper backup log book, “just in case.”
We all take basic infection precautions when performing procedures, including alcohol hand gel, eye protection, gloves, mask, and cleaning of surgical sites prior to excision. When there are wound infections, which should be rare, you should always culture, and if there is a cluster of infections, particularly with methicillin-resistant staphylococcus aureus (MRSA), you should consider culturing the anterior nares of the staff. Alternatively, you can preemptively treat the staff with intranasal topical mupirocin daily for 2 weeks.
Measuring the use of alcohol gel before and after staff education is an easy and beneficial quality improvement project. You and your staff are, of course, vaccinated for hepatitis B, and yearly for influenza, and you should consider PPD testing every 2 years for everyone. My asymptomatic receptionist converted, and needed prophylactic tuberculosis treatment and contact tracing.
Wrong-site surgery is a frequent problem for dermatologists. Many of our biopsies are tangential, heal almost invisibly, without marking sutures, and patients have battle-scarred skin, and are elderly. The patients may have trouble remembering or seeing where the biopsy was, so good charts and family members are helpful. Photographs of the biopsy sites can be priceless. If the site still cannot be identified, then rebiopsy, or close follow-up is indicated.
Emergencies are rare, but it is prudent to have an automatic external defibrillator in the office. These are automated, so Advanced Cardiovascular Life Support (ACLS), or even basic CPR is not required to operate them, and the survival rate after cardiac arrest increases from 2% to 50%. When it has to be replaced after 5 years, take the old one home and teach your spouse how to use it, and maybe they will.
If you do a lot of surgery you may want to get the ACLS training and buy the crash cart drug kit, but many of the drugs have become ferociously expensive, despite being generic.
Staff safety is a crucial consideration and showing concern boosts staff morale. You should dispose of sharps directly into a sharps container and remove the sharps from the tray at the end of the case. You should have a written protocol for needle sticks. I keep the red top tubes, and the first 2 days of HIV medication on site. Sometimes a patient is HIV positive, the sharp exposure is unknown (a cryostat tissue tease for example), or the patient refuses to have their blood drawn. Less obvious, but important to staff, are locks on doors, alarm systems, good parking lot lighting, and security cameras.
Office safety may seem mundane but a few simple measures can save you a fortune, boost employee morale, and most important of all, improve patient care.
Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of more than 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics. Reach him at dermnews@frontlinemedcom.com.
