Boards and Beyond:

Behavioral Science

A Companion Book to the Boards and Beyond Website

Jason Ryan, MD, MPH

2018 Edition

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 Table of Contents

Ethics Principles 11 Informed Consent 5

Confidentiality 10 Decision-Making Capacity 13
Public Health 16 Quality and Safety 20

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 Ethics

Ethical Principles

Principlism Autonomy

Autonomy Autonomy

Avoid judging, threatening, or scolding

1
Beneficence Non-maleficence

Risk versus benefits

Justice Gifts from Companies

Form of “distributive justice”

Honoraria Gifts from Patients

ed as given in exchange for special treatment

2
Romantic Relationships Patient-Physician Relationship

Medical Errors Family and Friends

Family of Patients Noncompliant Patients

Provide more information

3
Emotional Patients

4
 Informed Consent

Informed Consent

Informed Consent Informed Consent

Other therapies

Informed Consent Informed Consent

Non-life-threatening diagnosis detected in OR

5
Informed Consent Emergencies

Therapeutic Privilege Therapeutic Privilege

Patient autonomy most important guiding principle

Waiver Minors

Emancipated minors
Special situations

6
Minors Emancipated Minor

Classic example: Parents are Jehovah's Witnesses Military service

Minors Abortion

Prenatal Care
Treatment for STDs
Treatment for substance abuse

Abortion Organ Donation

7
Organ Donation DNR

Moskop J. AMA Journal of Ethics. Organ Donation:

When Consent Confronts Refusal. Feb 2003; 5(2)

DNI Advance Care Planning

Advance Care Planning Research

DNR/DNI status (“code status”)

Heart Failure

8
Research Research

Many companies sponsor research

Pregnancy Documentation

Alternative: someone VERY familiar with procedure

Documentation

9
 Confidentiality

Confidentiality

HIPAA Confidentiality

Need patient’s permission

Confidentiality Confidentiality

“Directory information”

10
Tarasoff Case Duty to Warn and Protect

STDs STDs

www.aids.gov

Reportable Illnesses Abuse

Prevent infectious disease outbreaks

https://wwwn.cdc.gov/nndss/conditions/notifiable/2017/

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Spousal Abuse Driving

Driving

12
 Decision-Making Capacity

Decision-Making
Capacity

Competency Decision-Making Capacity

Patient understands disease and therapy

Related to understanding
Patient understands how disease/therapy affects him/her

Compare options

Decision-Making Capacity Intellectual Disability

Appreciation of facts

13
Patients Who Lack Capacity Advance Directives

Living Will DPAHC

Absence of Advance Directive Surrogate Designation

#3: Parents

14
Brain Death

15
 Disease Prevention

Public Health

Primary Prevention Secondary Prevention

Tertiary Prevention Quaternary Prevention

Radiology tests
Coronary procedures

16
US Healthcare Emergency Care

Private insurance

Medicare Medicare

Hospital payments

Outpatient treatment

Prescription drug coverage

Medicare Medicaid

17
Private Insurance Private Insurance

Insurance companies hires providers

Less expensive

Health Maintenance Organization (HMO)

Preferred Provider Organization (PPO)

Private Insurance Private Insurance

Most expensive plan

Payment Types Affordable Care Act

Financial risk transferred to physician/hospital

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Hospice

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 Quality and Safety

Quality and Safety

Care Transition Medication Reconciliation

Name, dosage, frequency, route

Admission to hospital

Antimicrobial Stewardship SBAR

Prevent emergence of drug-resistant bacteria

Prescribing patterns

20
Quality Measurements Hospital Readmission

Patient discharged too early

Follow-up not scheduled

Hospital Readmission Pressure Ulcers

Medicare Medicaid Private Insurance Uninsured

Heart Failure Mood Disorders Chemotherapy Mood Disorders
Sepsis Schizophrenia Mood Disorders Alcoholism Special mattresses (redistribute pressure)
Pneumonia Diabetes Surgical Complications Diabetes Early identification/care skin breakdown

Healthcare Cost and Utilization Project. Conditions With the Largest

Number of Adult Hospital Readmissions by Payer. April 2014

Pressure Ulcers Surgical Site Infections

21
Central Line Infections VAP

DVT Never Events

Virchow’s triad
Stasis, hypercoagulable state, endothelial damage

Wrong surgical procedure performed

Early ambulation
Intermittent pneumatic compression Administration of incompatible blood
Subcutaneous heparin
Low molecular weight heparin (Enoxaparin)

Physician Quality Quality Measurements

Measurements
Foot exams
Eye exams

ACE inhibitors

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Prevention and Safety Infection Control Precautions

Standard Precautions
Droplet Precautions
Contact Precautions
Airborne Precautions

Standard Precautions Contact Precautions

Any infectious diarrhea (norovirus, rotavirus)

Especially clostridium difficile

Droplet Precautions Respiratory Precautions

Fever, cough
Immunocompromise
Respiratory viruses, especially influenza, RSV
Neisseria meningitides
Bordetella pertussis

College Student
Fever, neck pain

23
Immunizations Root Cause Analysis

Wrong drug administered to patient

PPSV23: Contains capsular polysaccharide antigens Nursing error?

Failure Mode & Effects Analysis Types of Errors

Frontline/bedside operator error

Patient Skin
Lidocaine
Positioned Cleaned

Swiss Cheese Model PDSA

Institutional factors
Supervisor errors
Environmental factors
Individual error

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PDSA Time Out

Checklist Triggers and Rapid Response

Central-line infections
Surgical-site infections Low oxygen saturation

Provider group

Forcing Functions Human Factors Design

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Human Factors Design Culture of Safety

Same procedures followed throughout hospital

High Reliability Organization

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