Prepared For

2009 ANCC National Magnet Conference

October 1, 2009

By

Jane Menendez, RN

Ann Schramm, RN, MSN

Improving Culture and Learning from Errors with a Nursing Morbidity and Mortality Program

This Discussion will Cover . . .

• The Goal: A Culture of Safety

• Morbidity & Mortality Programs

– How to

–Design

–Implement

–Use the findings

–Evaluate

Northwestern Memorial Hospital

• Mission: “Academic Medical Center Where the Patient Comes First”

• Strategic Goals: Best Patient Experience, Best People, Exceptional Financial Performance

• Primary Teaching Affiliate of Northwestern University’s Feinberg School of Medicine (>500 Residents / 125 Fellows)

• RNs 2223

Page 3

State of the Art Facilities

• $580 Million Redevelopment Project

• 3 Million square feet covering one city block

• High Tech – “Most Wired”

• Level I trauma networks and

Level III neonatal intensive care unit – 9000+ deliveries

Total Beds: 897

Total Admissions: 43,312

Total Outpatient Visits: 438,979

Total Outpatient Clinics: 13

ED Visits: 73,881

Average Daily Census: 596

Pursuing a Culture of Safety

What does a culture of safety look like?

• Organizational commitment to create and support safe systems

• Environment in which individuals feel free to – identify errors

– openly question the safety of existing systems, and

– constructively analyze problems

• Errors are used for learning and for improving

• Hierarchies are flattened

• Transparency at all levels is encouraged

Dana-Farber Cancer Institute Principles of a Fair and Just Culture, Dana-Farber Cancer Institute, accessed at www.dana-farber.org/abo/news/tools/justculture.asp.

Who creates and exhibits a culture of safety?

• The environment for the culture is created by organizational leadership, which provides the atmosphere and opportunities for learning from error

• The culture is adopted by staff members at all levels of the organization, who respond to and benefit from the created environment

Wilkins BA. (2004). A brief summary of concepts from nuclear energy’s work to develop a safety culture. Inova Health System.

High Reliability Organizations

• Preoccupation with failure

• Reluctance to simplify interpretations

• Sensitivity to operations

• Commitment to resilience

• Deference to expertise

Weick KE & Sutcliffe KM (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass.

How Do You Know Whether You Have a Culture of Safety?

• Incident reporting

• Interdisciplinary collaboration

• Walk Rounds

• Collegial rapid improvement projects

• Metrics such as AHRQ Hospital Survey on Patient Safety Culture (HSOPSC)

National Challenges in Culture of Safety

AHRQ Hospital Survey on Patient Safety Culture (HSOPSC)National Data: 382 hospitals and 108,621 hospital staff respondents • Highest scores for Teamwork Within Unit• Lowest scores for Nonpunitive Response to Error: “the lowest average

percent positive response (43 percent), indicating this is an area with potential for improvement for most hospitals….”

• “The survey item with the lowest average percent positive response (35 percent) was: "Staff worry that mistakes they make are kept in their personnel file" (an average of only 35 percent strongly disagreed or disagreed with this item). “

Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report http://www.ahrq.gov/qual/hospsurveydb/hospdbch5.htm

How can we promote and support a culture of safety?For example . . .

• Create structure for the systematic review of safety concerns

• Establish care delivery practices that encourage teamwork and collegial relationships among members of different disciplines

• Institute human resource policies that support a non-punitive culture

• Create vehicles for sharing and learning from errors

Patient Safety Morbidity & Mortality Conference

Patient Safety M&M

• Created in 2003 to

– Openly identify and examine errors that occur in our hospital

– Perform a retrospective analysis (root cause analysis) with an interdisciplinary group

– Bring members of all disciplines together to share information and problem-solving efforts

– Bring lessons learned and solutions back to M&M participants

–Encourage further event reporting

Introducing the Idea and Initiating the Conference

• Identify needed champions

• Ensure agreement on goals and process from other interested departments (e.g., Risk Management, Medicine, Nursing, Pharmacy)

• Establish organizational coverage for the M&Ms to maintain their status as quality initiatives according to your state law

• Identify needed resources (e.g., personnel for planning, meeting space, time allotment for staff to attend/complete)

Patient Safety M&Ms: Two Forums, Two Audiences

1. Interdisciplinary Patient Safety M&M– Monthly live conference, beginning at noon for one hour in large conference

room that can seat up to 100 people

– Notice of conference sent via email each month; interesting title

– Lunch served to attendees

– Nursing contact hours and ACCME credits for physicians offered for each program

2. Nursing Patient Safety M&M– Monthly online module completed by staff nurses

– Case study directly related to nursing care

Interdisciplinary M&M Monthly Meeting

Interdisciplinary Patient Safety M&MProgram Organization

• Case study selected each month based on– High priority recent events reported via incident reporting system

– Other events related to ongoing clinical care / safety initiatives within the organization (e.g., falls, medication reconciliation, handoffs)

– On occasion, an event that occurred elsewhere, but could have happened at our hospital

• Panel is selected for each conference– Panel members represent the disciplines involved in the actual event

– Typically physician, nurse, pharmacist

– May or may not have been actually involved in the event

Program Agenda

• Program begins with review of prior month’s case with key findings and recommendations from the M&M participants

2. Presentation of Case Study

The case is read; all audience members have a hard copy for reference.

1. Closing the Loop on Previous M&M Findings

Program Agenda

3. Discussion, Root Cause Analysis (VA National Center for Patient Safety model), and Plan for Improvement

VA Root Cause Framework– Human Factors – Communication

– Human Factors – Training

– Human Factors – Fatigue/Scheduling

– Environment/Equipment

– Rules/Policies/Procedures

– Effective Barriers/Controls to Protect Patient Safety

Example Interdisciplinary M&M

Sample M&M: Follow Up From Prior MonthFollow-up from September’s Case Studies: The Wrong Patient: Tests, Medications, and Procedures Performed after Errors in Patient Identification

Key Findings Recommendations Patients are frequently identified by care providers without going through all of the designated steps of the patient identification process.

Patient identification must include: the use of two identifiers (e.g., patient

name and date of birth); confirmation of the patient’s first and

last name; and requesting the patient to state his/her

name (if able).

Patients are not always familiar with the procedures they are scheduled to have and may not have adequate knowledge to notify providers if an incorrect procedure is begun.

Attempt to better inform patients about the procedures for which they are scheduled so that they can more easily recognize whether the preparation and procedure seem appropriate to their clinical condition. Empower patients to speak up if they think that some aspect of their care or treatment seems incorrect.

Interpretation of HIPAA requirements may lead to error-prone patient identification practices.

Perform a reassessment of HIPAA privacy requirements to ensure that patient identification practices do not introduce unnecessary risk.

Sample M&M: Case Study for This Month

JW is a 42 year old female who presented to the Emergency Department on 7-10-07 with complaints of fever, chills, right flank pain, and pain on urination. She was diagnosed with pyelonephritis, given a first dose of intravenous ciprofloxacin in the Emergency Department at 0100 on 7-11, and admitted for continuation of intravenous antibiotics. The order for intravenous ciprofloxacin was placed as a “pharmacy to dose” order by the admitting physician. The order was verified by the pharmacist, but a dosed order was never entered. On the following day, 7-12, the patient complained of increasing abdominal pain so a CT scan was completed which revealed pyelonephritis. It was then discovered that the patient had not received any intravenous ciprofloxacin since the first dose in the Emergency Department. She received her second dose at 1800 that day (7-12), 41 hours after her first dose. Her pain improved and her white blood cell count began to fall. She was discharged home two days later.

Sample M&M: Case Study Discussion Guide

Triage Questions

• Were issues related to patient assessment a factor in this situation?

• Were issues related to staff training or staff competency a factor in this event?

• Was equipment involved in this event in any way?

• Was a lack of information or misinterpretation a factor in this event?

• Was communication a factor in this event?

• Were appropriate rules/policies/procedures – or the lack thereof – a factor in this event?

• Was the failure of a barrier designed to protect the patient, staff, equipment, or environment a factor in this event?

Sample M&M: Case Study Discussion Guide

Focus on the following six categories

• Human Factors – Communication

• Human Factors – Training

• Human Factors – Fatigue/Scheduling

• Environment/Equipment

• Rules/Policies/Procedures

• Effective Barriers/Controls to Protect Patient Safety

Interdisciplinary M&M – Evaluation

Item Score, average

(range 1-4, 4 is highest)

Overall assessment of program 3.82

As result of this program, I can describe patient safety issues with a focus on systems.

3.82

As a result of this program, I can describe the process and components of a root cause analysis.

3.62

As a result of the program, I can describe strategies to improve patient safety.

3.75

Nursing Online M&M

Nursing M&MProgram Organization

• Case study selected each month based on– Relevance to nursing practice

– High priority recently reported events

– Other events related to ongoing clinical care / safety initiatives within the organization (e.g., medication administration)

– On occasion, an event that occurred elsewhere, but could have happened at our hospital

• Online PowerPoint module created and posted online– Nurses complete on their own

– Managers have 85% completion goal for their staff

Example Nursing M&M Module

NMH Patient Care Division

Patient Safety

Morbidity/Mortality Study Module

Patient Identification

November 2007

ExitExit

Picture is for illustration purpose only

Upon Completion . . .

Participants will be able to:

• Identify the importance of performing a thorough and accurate identification of any patient prior to providing any patient care service.

• State the required components of the patient identification process.

• Describe the unintended consequences of incorrect patient identification.

• Explain methods for improving patient identification procedures in their area of practice.

Accurate Patient Identification

The accurate identification of patients prior to the provision of care – particularly the administration of

medications or the performance of any invasive procedures – is an important role of professional nurses in caring and advocating for their patients.

Picture is for illustration purpose only

Case Study #1

Picture is for illustration purpose only

Ray Williams*, a 53 year old male, was scheduled for a paracentesis in Interventional Radiology (IR) on 09-04-07. When the IR staff were ready to have the patient transported, they selected the name of another patient, Roy Williams, in the teletracking system. The transporter received the request for Roy Williams and picked him up and transported him to IR for the procedure.

Roy Williams arrived in IR. In the holding area, a nurse discovered that he was not the patient scheduled for the procedure and he was returned to his room. Mr. Williams was angry and frightened by the error.

*All names have been changed.

Case Review

1. In case study #1, at what point(s) in the process were there errors or lapses in patient identification?

A. Requesting the patient in the transport teletracking system

B. Correct patient identification by the transporter in the patient’s room

C. Identification of the patient by the transporter and the patient’s nurse on the inpatient unit (handoff)

D. Identification of the patient by staff in the IR holding area

E. A and C

F. All of the above

Case Review

• Great Job!– In this case, the incorrect identification of the patient began when the

IR staff selected the wrong patient name in the transport tracking system. The error continued unrecognized because the transporter and nurse on the inpatient unit had no communication prior to the patient being picked up and taken to IR. Had the nurse been contacted, she would have recognized that the patient being picked up was not scheduled for an IR procedure on that day.

Case Review

• Incorrect. The correct answer is . . . – A and C. In this case, the incorrect identification of the patient began

when the IR staff selected the wrong patient name in the transport tracking system. The error continued unrecognized because the transporter and nurse on the inpatient unit had no communication prior to the patient being picked up and taken to IR. Had the nurse been contacted, she would have recognized that the patient being picked up was not scheduled for an IR procedure on that day.

– The transporter correctly identified the patient in his room and the nurse in the IR holding area also correctly identified the patient, leading to the discovery of the error.

Nursing M&M – Evaluation

• Online survey conducted to obtain nurses’ assessment of Nursing M&M

– Survey items taken from AHRQ HSOPSC survey

– 307 nurses responded, representing full range of clinical areas – February – March 2008

– Responses compared to hospital-wide HSOPSC culture survey responses for 716 nurses from May 2006

Nursing M&M Survey Results

Nurse Responses

77

63 62

90 8984

50

60

70

80

90

100

We are actively doingthings to improve

patient safety.

We discuss ways toprevent errors from

happening.

Mistakes have led topositive changes here.P

er C

ent

Po

siti

ve R

esp

on

se May 2006 Feb/March 2008

Nursing M&M Survey Results

Nurse Responses - February/March 2008

626466687072747678

The M&M programshelp me to understandpatient safety issues

with a focus onsystems.

The M&M programshelp me to identify

strategies to improvepatient safety on my

unit.

The M&M programsare relevant to me in

my position.

Per

Cen

t P

osi

tive

Res

po

nse

s

Nursing Feedback on M&M Program

• Nurses in Neonatal Intensive Care Unit and obstetrics brought to our attention that – “Scenarios are never geared towards maternal-fetal medicine.”

– “I feel like they never pertain to our unit.”

– “Would like to see some more neonatal specific, rather than adult based.”

Many positive comments, but some constructive criticism as well

Nursing Feedback on M&M Program

• Some nurses preferred the original format, which involved case presentation and discussion at a staff meeting– “I think it was more beneficial when they were done by the

manager.”

– “I like the way we used to do M & Ms, which was discussing as a group during staff meetings.”

Nursing Feedback on M&M

• Favorable responses overall– “It is truly an eye opener to learn how mistakes are made and how

NMH has come up with many safety tools and policies to prevent them.”

– “It is important to learn from actual cases that occur here at NMH and the M&Ms mostly help as refreshers to how we should be practicing and hopefully change people's bad habits.”

– “I think that it is a great idea to learn from mistakes that did occur. This teaches staff that it is human to err.”

Summary

• Patient Safety M&Ms have contributed to the creation of a culture of safety at Northwestern Memorial Hospital and have provided a valuable forum for the sharing of experiences, ideas, and problem solving among clinicians of multiple disciplines.

• We will continue to “reinvent” both programs based on feedback from participants to maximize the programs’ usefulness for providers.

Questions / Discussion