Oct 23 CAPHC Patient Safety Symposium - Trey Coffey
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Transcript of Oct 23 CAPHC Patient Safety Symposium - Trey Coffey
Our first 18 months with SPS
Trey CoffeyCAPHC Patient Safety Symposium
Oct 22, 2016@trey_coffey_TO
#caringsafely
Error Preventio
n
High Reliability
Safety Governanc
e
Leadership Methods
Family Engageme
nt
Cause Analysis
Four Objectives of Caring Safely*
1.Reduce the incidence of Serious Safety Events (SSEs) by two-thirds
2. Improve Staff Safety by reducing lost time injury count, frequency rate and/or severity by 20%
3. Reduce the incidence of the seven Hospital Acquired Conditions (HACs) significantly
4.Enhance our Safety Culture by adhering to the principles of High Reliability Organizations
* April 2015 – March 2018
Taking on all patient and staff harms simultaneously
•Central line infections•Surgical site infections•Pressure Injuries•Catheter-associated Urinary tract Infection•Ventilator associated pneumonia•Falls with significant harm •(Adverse Drug Events)
Bundle reliability: Set teach audit the standard
• Delayed recognition/response to deterioration, e.g. sepsis
• Failure to respond to results of investigations
• Errors in decision-making• Failure to use expertise
High Reliability Culture: Error prevention strategies Leadership methods RCA System redesign
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Hospital Acquired Condition Network Center Line SickKids Center LineAdverse Drug Event 0.03/1000 pt days
Catheter Associated Urinary Tract Infections
1.35/1000 catheter days
Central Line Associated Blood Stream Infections
1.52/1000 line days
Falls (Moderate or Greater Injury) 0.02/1000 pt days
Pressure Injuries (formerly ulcers) 0.11/1000 pt days
Surgical Site Infections 1.71/100 procedures
Ventilator Associated Pneumonia 0.54/1000 vent days
Benchmarking against Network data helps to identify priorities of focus and accomplishments to celebrate and sustain
Culture Work
Daily Safety Brief
Too easy to hide lack of progress
HOW CAN WE PREVENT THIS?SUMMARY OF EVENT
Capturing EventsThe Case of the: <title><Date>
WHY DID THIS EVENT HAPPEN?
The story presented above is an example of patient safety events occurring in hospitals across the country. As a learning organization, telling these stories is intended to generate dialogue among frontline caregivers who may be able to prevent a similar occurrence. For internal use only.
HOW CAN WE SUPPORT THE CULTURE OF SAFETY?
Caring Safely: Error Prevention Education
Caring Safely Trainers
Trained to DateEP = 2609/8000LM = 375/700
‘We’re not going to compete on safety’: Canadian paediatric health centres collaborate on journey to eliminating preventable harm
Clinical and operational leaders from SickKids, CHEO, and IWK came together to share ideas and key learnings about the journey to reducing preventable harm.
@trey_coffey_TO#caringsafely
Serious Safety Event: Event involving a deviation from Generally Accepted Practice Standard causing moderate to severe harm
© 2006, HPI, LLC
Precursor event: Event that DID reach patient but resulted in minimal or temporary harm.
Near Miss: Event that almost happened, but error was caught
Critical Incident
Serious Patient Safety Incident
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