1 The Science of Improving Patient Safety and Identifying Defects DRAFT – final pending AHRQ...

1

The Science of Improving Patient Safety and Identifying Defects

DRAFT – final pending AHRQ approval

Lisa Lubomski, PhD

November 11 and 13, 2013


Where are we now?

Give your frontline staff the vision to see system-level defects, and the voice to create a local SSI prevention bundle they can own.

Learning Objectives

3

After this session, you will be able to:

Apply Science of Safety into your work

Educate your team and executive partners on the Science of Safety

Identify defects within your OR by administering the Perioperative Safety Staff Assessment (PSSA)

Distribute and share PSSA results with your SUSP team

Locate SUSP resources on the project website to help complete the above tasks



Comprehensive Unit-based Safety Program (CUSP)1

4

CUSP for Surgery

1. Educate staff on science of safety

2. Identify defects

3. Recruit executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

We are here

Adaptive Work

5


Advances in Medicine: Lingering Contradictions

Advances in medicine have led to positive outcomes:

Most childhood cancers are curable

AIDS is now a chronic disease

Life expectancy has increased 10 years since the 1950s

However, sponges are still found inside patients’ bodies after operations. Postoperative X-Ray Reveals Unwanted

Situations2


Why is your SUSP work important?10

6

1 in 25 people will undergo surgery

7 million (25%) in-patient surgeries followed by complication

1 million (0.5 – 5%) deaths following surgery

50% of all hospital adverse events are linked to surgery AND are avoidable

7


How Can These Errors Happen?

People are fallible

Medicine is still treated as an art, not a science

Systems do not catch mistakes before they reach the patient


Educate staff on the Science of Safety12, 13

8

• Understand that the system determines performance and safety is the property of the system

- Majority of errors don’t belong to individual doctors or nurses

• Use strategies to improve system performance

- Standardize

- Create independent checks for key processes

- Learn from mistakes

• Recognize that teams make wise decisions with diverse and independent input


System Factors Impact Safety14

9

Hospital

Departmental Factors

Work Environment

Team Factors

Individual Provider

Task Factors

Patient Characteristics

Institutional

10


Safety is a Property of the System

http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/videos/04b_safeproperty/index.html



11




- Standardize




12


Standardize When You Can

http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/videos/04c_standardize/index.html


Create Independent Checks

13

http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/videos/04d_indchecks/index.html



14




- Standardize




http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/videos/04c_standardize/index.html


Communication Breakdowns

15


Basic Components and Process of Communication21

16


Comprehensive Unit-based Safety Program (CUSP)1

17

CUSP for Surgery

1. Educate staff on science of safety

2. Identify defects

3. Recruit executive to adopt unit

4. Learn from one defect per quarter

5. Implement teamwork tools

We are here

Adaptive Work


What is a defect?

18

Anything that happens that you do not

want to happen again.

19


Defect Intervention

Unstable oxygen tanks on beds

Oxygen tank holders repaired or new holders installed institution wide

Medication look-alikeEducation conducted, medications physically separated, and letter sent to manufacturer

Missing equipment on cart Checklist developed for stocking cart

Inconsistent use of Daily Goals rounding tool

Consensus reached on required elements of Daily Goals rounding tool

Inaccurate information by residents during rounds Electronic progress note developed

Examples of Defects That Affect Patient Safety


How can your team identify defects?

20

Event reporting systems, liability claims, sentinel events, M&M conference

Perioperative Staff Safety Assessment (PSSA) – completed by all staff members (not just medical) in the clinical area


PSSA taps into the wisdom of frontline providers

21

Frontline providers:

– Understand the patient safety risks in their clinical areas

– Have insight into potential solutions to these problems

We need to tap into this knowledge and use it to guide safety improvement efforts


What is the Perioperative Staff Safety Assessment (PSSA)?

22

Asks providers to complete 4 questions:

Please describe how you think the next patient in your unit/clinical area will be harmed

Please describe what you think can be done to prevent or minimize this harm

Please describe how you think the next patient in the OR will get a Surgical Site Infection

Please describe what you think can be done to prevent this Surgical Site Infection


When and Who administers the PSSA?

23

Who: SUSP project lead or a designee

Recommendation: Administer PSSA following training on the Science of Safety – providers will have lenses to see system problems

To encourage staff to report safety concerns, establish a collection box or envelope in an accessible location where completed forms can be dropped off

Staff should complete the PSSA at least every 6 months


What do you do with the PSSA results?

24

Prioritize identified defects using the following criteria:

Likelihood of the defect harming the patient

Severity of harm the defect causes

How commonly the defect occurs

Likelihood that the defect can be prevented in daily work


How will the next patient be harmed? (SSI Specific)22

25

Percentage of Responses (%)


PSSA follow-up

26

It is crucial that physician and nurse leaders respond to staff patient concerns

The SUSP team and other leaders must be ready to follow-up on the defects identified on the PSSA

You will use PSSA data to create your local surgical care improvement bundle


Next steps

27

**Present the SOS video and administer PSSA during these ideal times:

Medical staff Grand Rounds

New staff orientation

Regularly scheduled staff meetings (for nurses, surgeons, anesthesiologists, etc)

Lunch and learn sessions

Special educator sessions

Make video available in break room

Hang up SOS factsheet in break room, restroom, etc.

Annual recertification requirements

Hospital Intranet


Next StepsEngage staff who’ve watched the video

28

Discuss safety events in the clinical area

What systems may have led to these events?

How can the principles of safe design be applied to prevent future events?

How can staff and others in the clinical area improve communication?

How can these concepts be applied in the SUSP project?


Next stepsUse these tools to educate staff on the Science of Safety

29

Next step Tools to use Location of toolEducate SUSP team on Science of Safety (SOS)**

Science of Safety videoScience of Safety training attendance sheet

A Live Walkthrough of the SUSP Website!

Administer Perioperative Staff Safety Assessment (PSSA) to SUSP team**

Perioperative Staff Safety Assessment

Hang SOS factsheet in break room, rest room, etc.

SOS factsheet

Collate results of PSSA and share with SUSP team

Reference this presentation for help with sharing results


References

30

1. Pronovost P, Cardo D, Goeschel C, et al. A Research Framework for Reducing Patient Harm. Oxford Journals. 2011; 52(4): 507-513.

2. http://home.earthlink.net/~radiologist/tf/050800.htm

3. Bates DW, Cullen DJ, Laird N, et al. Incidence of Adverse Drug Events and Potential Adverse Drug Events. ADE Prevention Study Group. JAMA. 1995; 274(1): 29–34.

4. Donchin Y, Gopher D, Olin M, et al. A Look Into the Nature and

Causes of Human Errors in the Intensive Care Unit. Crit Care Med.

1995; 23(2):294-300.

5. Andrews LB, Stocking C, Krizek T, et al. An Alternative Strategy for

Studying Adverse Events in Medical Care. Lancet. 1997; 349(9048):

309-313.

http://home.earthlink.net/~radiologist/tf/050800.htm






References

31

6. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.

7. Scott, RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. March 2009. http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

8. Klevens M, Edwards J, Richards C, et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR. 2007;122:160–166.

9. 8. Ending health care-associated infections, AHRQ, Rockville, MD; 2009. http://www.ahrq.gov/qual/haicusp.htm.

http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

http://www.ahrq.gov/qual/haicusp.htm


References

32

10. World Health Organization. New Scientific Evidence Supports WHO Findings: A Surgical Safety Checklist Could Save Hundreds of Thousands of Lives. http://www.who.int/patientsafety/challenge/safe.surgery/en/. Accessed August 7, 2013.

11. Centers for Medicare and Medicaid Services. National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. Published March 2012. Accessed August 7, 2013.

12. Baker DP, Day R, Salas E. (2006), Teamwork as an Essential Component of High-Reliability Organizations. Health Services Research. 41:1576–1598.

13. Pronovost P, Goeschel C, Marstellar J,et al. Framework for Patient Safety Research and Improvement. Circulation Journal of the American Heart Association. 2009; 119:330-337.

http://www.who.int/patientsafety/challenge/safe.surgery/en/


References

33

14. Vincent C, Taylor-Adams S, Stanhope N. Framework for Analysing Risk and Safety in Clinical Medicine. BMJ. 1998;316:1154.

15. Healthcare-Associated Infection: A Preventable Epidemic. Committee on Oversight and Government Reform. http://democrats.oversight.house.gov/index.php?option=com_content&task=view&id=3649&Itemid=2. Accessed August14, 2013.

16. Center for Disease Control. Appendix B: Summary of Recommended Frequency of Replacements for Catheters, Dressing, Administration Set and Fluids. MMWR. 2002;51:RR-10.

17. Berenholtz S, Pronovost P, Lipsett P, et al. Eliminating Catheter-related Bloodstream Infections in the Intensive Care Unit. Crit Care Med. 2004; 32(10):2014-2020.


References

34

18. Pronovost P, Needham D, Berenholtz S, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med. 2006; 355:2725-2732.

19. Pronovost P, Goeschel C, Needham D. Sustaining Reductions in Catheter Related Bloodstream Infections in Michigan Intensive Care Units: Observational Study. BMJ 2010;340:c309

20. Website of the National Implementation of the Comprehensive Unit-based Safety Program to Eliminate Health Care-Associated Infections. http://www.onthecuspstophai.org/. Accessed August 7, 2013.

21. Dayton E, Henrikson K. Teamwork and Communication: Communication Failure: Basic Components, Contributing Factors, and the Call for Structure. Jt Comm J Qual Patient Saf. 2007; 31(1):34-47.

22. Wick EC, Hobson DB, Bennett JL, et al. Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections. J Am Coll Surg. 2012;215(2):193-200.

1 The Science of Improving Patient Safety and Identifying Defects DRAFT – final pending AHRQ...

Documents

Transcript of 1 The Science of Improving Patient Safety and Identifying Defects DRAFT – final pending AHRQ...