Improving Patient Safety with Team Training

Raleigh, North Carolina

WakeMed Health & HospitalsAmar P. Patel, MS, NREMT-P, CFCManager, Medical Simulation Centerhttp://www.wakemed.org/landing.cfm?id=1097&oTopID=616

Although it is a rare occurrence, pilots regularly rehearse engine failure in simulators. So when f d ith l it ti h bit t kfaced with a real situation habit takes over. Simulation enables people to train for rare events that do not occur often in real lifethat do not occur often, in real life.

~ Sir Liam Donaldson

Objecti esObjectives

Recall the overall risk for medical errors in the hospital environment and the top p p10 specific Sentinel Events by type.Recall the purpose of the 2009 National

Patient Safety Goal. List the components necessary for an

effective team training program. List the biggest challenges to

i l ti t t i iimplementing team training programs.

O er iewOverview

Risk for medical errorsTop 10 sentinel eventsTop 10 sentinel eventsNational Patient Safety GoalsEffective team trainingEffective team trainingChallenges to implementation

All humans make mistakes.Healthcare workers are human.Healthcare workers make mistakesHealthcare workers make mistakes.

~ Dr. Meera Kelley

O er ll RiskOverall Risk

Nearly 100,000 people die annuallyannuallyFewer then 3% of hospitals have

an electronic drug ordering systeman electronic drug ordering system2003-2008 survey revealed:

- 39% of physicians admitted to at least 1 medical error.C f ti t di t- Cause = fatigue, stress, distress,

Top 10 Sentinel EventsT p S

http://www.jointcommission.org/NR/rdonlyres/241CD6F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats12_08.pdf

DefinitionDefinition

Any unanticipated event in a h lth tti lti i d thhealthcare setting resulting in death or serious physical or psychological injury to a person or persons, not related to the natural course of the patient’s stress.

~ The Joint Commission

# 10# 10

Patient death / injury in restraints

196

3.1%

# 9# 9

Perinatal death / loss of function

197

3.2%

# 8# 8

Assault / rape / homicide

241

3.9%

# 7# 7

Unintended retention of foreign body

285

4.6%

# 6# 6

Patient fall

396

6.3%

# 5# 5

Delay in treatment

507

8.1%

# 4# 4

Medication Error

520

8.3%

# 3# 3

Op / post-op complication

695

11.1%

# 2# 2

Suicide

752

12%

# 1# 1

Wrong-site Surgery

837

13.4%

To 10 Sentinel E entsTop 10 Sentinel Events

Event Number of OccurrencesPatient death / injury in restraints 196Perinatal death / loss of function 197Assault / rape / homicide 241Unintended retention of foreign 285Unintended retention of foreign body

285

Patient fall 396Delay in treatment 507Delay in treatment 507Medication error 520Op / post-op complications 685Suicide 752Wrong-site Surgery 837

Uni ers l ProtocolUniversal Protocol

How can we change this?g

How can we inspire a safer k l ?workplace?

Americ n Hos it l Associ tionAmerican Hospital Association

http://www.ahaqualitycenter.org/ahaqualitycenter/jsp/home.jsp

Sentinel event settingsS g

http://www.jointcommission.org/NR/rdonlyres/241CD6F3-6EF0-4E9C-90AD-7FEAE5EDCEA5/0/SE_Stats12_08.pdf

Sentinel E ent SettingSentinel Event Setting

Location Number of OccurrencesGeneral hospital 4226Psychiatric hospital 665y pPsych unit in general hospital 311Emergency department 284Behavioral health facility 281Behavioral health facility 281

Human Factors…

DefinitionDefinition

The science of understanding the properties of human capabilityproperties of human capability.

~ Elias Porter, Ph.D

DefinitionDefinition

Those elements that influence the performance of people operating equipment or systems; they includeequipment or systems; they include behavioral, medical, operational, task load machine interface andtask-load, machine interface and work environment factors.

T t C d~ Transport Canada

In healthcare, what can we t?prevent?

In healthcare, how can we t ?prevent errors?

Who is responsible?p

Just Routine O er tionJust a Routine Operation

http://vimeo.com/970665

All humans make mistakes.Healthcare workers are human.Healthcare workers make mistakesHealthcare workers make mistakes.

~ Dr. Meera Kelley

2009N ti l P ti t S f t G lNational Patient Safety Goal

http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/

2009 NPSG2009 NPSG

9 categories- Ambulatory Health Care- Behavioral Health Care- Critical Access Hospital- Disease-specific Care- Home Care- Hospital- Laboratory- Long-term Care- Office-based Surgery

Goals evolve yearly 2010 in pre-Goals evolve yearly, 2010 in prepublication

2009 NPSG2009 NPSG

Purpose:- A method by which JCAHO promotes- A method by which JCAHO promotes

and enforces major changes in patient safety in thousands of p yparticipating organizations around the world.

- Often target very specific areas such as infections or falls, other times they h id fhave a wider focus.

Effective Team Trainingg

Te m Tr ining 101Team Training 101

CommunicationMulti & Interdisciplinary educationMulti- & Interdisciplinary educationProcess changes / analysisEffective debriefingObject driven educationjConsider developed programs

- TeamSTEPPS (evidence-basedTeamSTEPPS (evidence based teamwork system)

Te mSTEPPSTeamSTEPPS

http://teamstepps.ahrq.gov/

Te m Tr ining 101Team Training 101

“Simulation isn’t an option, it is a MUST ”MUST.Scenario designed to meet the

needneedRealistic1 person is not responsible, the

TEAM is.

What do you need to make thi ff ti ?this effective?

Australia Department of Defense

M nikins or Simul torsManikins or Simulators

Could you use a manikin as a simulator?Could you use a simulator as a

manikin?What’s the difference?

TechnologTechnology

EquipmentComputer GamesComputer GamesSimulatorLearning Management SystemHow to use it?When to use it?

What about scenarios?

Scen rio De elo mentScenario Development

V lid tionValidation

Visual walk-through of scenarioSimulator driven walk throughSimulator driven walk-throughModifyRe-run scenarioObtain approvalspp

Tr nsl ting Scen riosTranslating Scenarios

Through QA/QI find casesChoose the simulatorChoose the simulatorPick everything in the case fileDevelop the scenarioDevelop a chart, remove patient p , p

info – create your own! Include X-rays/LabsInclude X rays/Labs

Scen rioScenario

X rX-ray

Progr m Focused QuestionsProgram Focused Questions

What do you believe to be your greatest strengths? (What cases are you the most comfortable with? What skills do you believe you have mastered?)

What do you believe to be your greatest weakness? (What cases are you theweakness? (What cases are you the least comfortable with? What skills do you believe you would like more time toyou believe you would like more time to practice?)

Self E lu tionSelf-Evaluation

Please discuss each participant’s role and responsibilities in the scenario. p

Please discuss what could have gone gbetter as the scenario evolved and provide suggestions for improvement.

Please discuss what went well and why you believe it did.

How does simulation impact ti t f t ?patient safety?

http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/

Challenges…g

http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals/

The Ch llengeThe Challenge

The pitch…The costThe cost…The people…Understanding the potential…The space…p

If we teach today the way we were taught y y gyesterday we aren't preparing students.~ Anonymousy

We need to replicate in the classroom the world in which students are living.~ Anonymous

What gets us in trouble is not what we don't know. It's what we know that just ain't so. ~ Mark Twain

Improving Patient Safety with TeamImproving Patient Safety with Team Training

Raleigh, North Carolina

WakeMed Health & HospitalsAmar P. Patel, MS, NREMT-P, CFCManager, Medical Simulation Center