© 2007 jhu quality and safety research group 1 learning from a defect: team exercise jill...

© 2007 JHU Quality and Safety Research Group

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Learning from a Defect:Team Exercise

Jill Marsteller, PhD, MPP

Workshop Objectives

• Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety Program.

• Describe the process used to identify and eliminate system defects.

• List three tools or strategies used to improve teamwork and

build a safety culture. • State research and best practices in reducing infections,

preventing central line infections, and going beyond the bundle.


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What is a Defect in Patient Care?

Definition-defect A defect is any clinical or operational

event or situation that you would not want to happen again. These could include incidents that you believe caused harm or put patients at risk for harm (Pronovost, P. et al., (2006) Tool

tutorial: A practical tool to learn from defects in patient care Journal of Quality and Patient Safety, 32, 102-108.)


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Sources of Defects

• Adverse event reporting systems• Sentinel events• Claims data• Infection rates• Complications• How is the next patient going to be

harmed


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Complication, LOS, Charges*

Complication

Increased LOS

Charges

Pneumothorax

4 days $17,000

PE or DVT 5 days $22,000

Hip Fx 5 days $13,500

Respiratory failure

9 days $53,000

DT’s 9 days $55,000

Post op sepsis

11 days $58,000

*Miller JAMA 2003


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7 System Factors Impact Safety

2.Hospital 3. Departmental

4. Work 5.Environment

6. Individual Provider 7. Task Factors

8. Patient Characteristics

1.Institutional

System Failures Can Come From Many Factors in an Organization

8 Major Factors thatcan contribute toSystem Failures


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Safety Efforts

• Focus on Harm versus errorsHarm- ignorance of causality- provider

levelError see provider level

• Proactive versus reactive


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LFD: A Four-step Process

The LFD Process steps

1.Answers the question: “What happened?”

2.Evaluates the defect3.Lists specific actions needed to reduce

the likelihood the defect will happen again

4.How do you know the action taken got the results you wanted?


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Step 1. Answer-What happened?

The Role of the investigator:– Construct a brief, concise statement of the “story”

surrounding the incident.

– Reconstruct the timeline of the incident or near miss

– Try to “view the world” as one of those involved in the event at the time the event happened: How were those involved thinking about the problem? Why did they make the decision they made? Why did they take the course of action that was taken?


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Step 2. Evaluate the defect

Evaluate the defect by– Reviewing and checking all the factors

that caused or negatively contributed to patient harm,

– Reviewing and checking all positive factors that might have reduced or eliminated harm


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Probes to Contributing Factors: Examples

Patient Was the patient acutely ill? Agitated? Anxious? Aged? Language barrier? Personal or social issues?

Task Was a stated policy/protocol or guidelines followed? Were labs available for decision making?

Caregiver Fatigue? Lack of experience by care givers? Any physical or mental health issues with provider?

Team Were handoffs (verbal or written) clear? Was there a clearly identified team leader? Were team members hearing one another’s concerns?

Training and Education Was established protocol followed? Were caregivers knowledgeable and competent?


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Probes to Contributing Factors: Examples Continued

Patient Was the patient acutely ill? Agitated? Anxious? Aged? Language barrier? Personal or social issues?

Information Technology

Did technology create an error? Technology malfunction?

Local Environment Were there adequate supplies and equipment? Were there adequate human resources to care for patients and support staff?

Institutional Environment

Was there adequate staff (lab, pharmacy, nurses)?

Other


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Step 3. Create an Action Plan

List specific actions to reduce the likelihood of the defect happening again.

-determine who will lead the defect investigation

-establish a follow-up date

-measure risk reduction using either a qualitative or quantitative measure.


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Step 3. Action Plan: Template Example

Specific actions needed to reduce the risk of the defect?

Who will lead this effort

Follow-up date

How will you know the risk to the patient is reduced?

Create a specific action plan to mitigate the occurrence of this type of incident or the near miss


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Step 4. How will you evaluate the impact of the intervention?

1.Develop a framework to assess the impact of the intervention.

2.What are your variables?3.How will they be measured?4.How long will you evaluate?

Utilize your clinical experts- often your frontline staff. If they don’t view it as important or effective it unlikely to be successful


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Step 4. How will you evaluate the impact of the intervention?

Example: VRE reduction Developed a new policy and procedure for skin

antisepsis.After education and Implementation

1.Evaluate the staff’s knowledge of the policy and procedure.

2.Is the policy and procedure being adhered to by the staff?

3.Summary of the staff’s perception of the impact of the intervention in preventing the defect?


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Walk Through- Case Study 1

•2-5 minute debriefing between teams at change of shift or hand-offs.•All staff stop and have a time-out prior to performing a procedure to discuss plan and any risks.

Develop a step-by-step checklist for performing a tracheotomy; make it standard policy to perform with ICU attending present.

Proper debriefing and clear procedural guidelines.

Poor communication among teams.

Standard policy and procedure for percutaneous tracheotomy replacement was not followed.

Surgical chief’s limited knowledge of trach placement difficulty, poor trach placement skills.

CASE IN POINT…..This case involves a chronically, critically ill white male over 65 years of age admitted to the ICU with a GI neoplasm. He had undergone GI surgery during this hospital admission and at the time of this adverse event was mechanically ventilated, with multiple infusions, inatropes and vasopressors. Due to failure to wean from mechanical ventilation, he underwent an uneventful percutaneous tracheostomy. During the first change of the patient’s percutaneous tracheostomy, the airway was lost, likely because the Shiley was placed in the subcutaneous tissue rather than the trachea, leading to hypoxia, hypotension, cardiac arrest and death. In reviewing the activities leading to this adverse event: (1) there was miscommunication between nursing staff and ICU team regarding the policy for trach replacement, resulting in a request for tracheostomy replacement; (2) surgical chief changed the trach after evening change of shift without adequate back-up; (3) surgical chief was unaware of patient’s worsening condition throughout the day and fellow was not aware of the planned trach change; (4) no verbal or written note given at change of shift noting difficulty of trach placement (done in OR); (5) neither the ICU attending (handling two admissions at the time) nor the surgical attending were notified of tracheostomy change in progress; (6) incorrect replacement trach tube used and inadequate positioning of patient; (7) ICU and surgical care teams failed to diagnose inadequate placement of replacement tube over red rubber catheter, attributing no EtCO2 or breath sounds to large cuff leak.

•Safety Tips: Team debriefings at change of shift or hand-offs.Time-outs for assessment prior to procedures.Checklist guidelines for complicated procedures.

•Safety Tips: Team debriefings at change of shift or hand-offs.Time-outs for assessment prior to procedures.Checklist guidelines for complicated procedures.

SYSTEM FAILURES: OPPORTUNITIES for IMPROVEMENT:


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Case Number 2

• Take a few minutes and familiarize with the case

• Review the investigate a defect tool.• Discuss with your team

Workshop Objectives

• Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety Program.

• Describe the process used to identify and eliminate system defects.

• List three tools or strategies used to improve teamwork and

build a safety culture. • State research and best practices in reducing infections,

preventing central line infections, and going beyond the bundle.


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© 2007 jhu quality and safety research group 1 learning from a defect: team exercise jill...

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