An Imperative for Performance Improvement

Neil G. Jaymalin, RN, MBAH, CQAFebruary 26, 2010

DefinitionPatient Safety is a new

healthcare discipline that emphasizes the reporting, analysis, and prevention of medical error that often lead to adverse healthcare events.

Fall PreventionPressure UlcersHand HygieneSurgical FireWrong Site /

Patient Surgery

• Patient Identification

• Proactive Risk Assessment

• Medication Safety

• Patient Involvement

• Staff Communication

Medication Safety◦Accounted for 9.9% of

the sentinel events reviewed by JCI

◦Policy cascade and promotion High Alert Meds PCA SALAD Labels Reconciliation (Drug

Profile)

StandardsJoint Commission – covers from

prescription to administration including monitoring of medication effect to patient

Approach to SafetyLeadership driven culture of

safety

Improve reporting of errors by establishing a non – blame environment

Evaluate where technology can help reduce the risk of medication error

Establish a fool proof method of controlling high alert medications

Patient Involvement

Establish a controlled formulary

Medication ErrorMedication ErrorJAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC

IPD Medication Error

0.19 0.19 0.22 0.12 0.16 0.14 0.20 0.16 0.06 0.06 0.12 0.00

IPD MEDICATION ERROR

0.00

0.05

0.10

0.15

0.20

0.25

Reported medication error / total dispensed medication * 1000Benchmark = 3.1 %

Practice RecommendationReporting Safety WalkroundsFMEA

ReportingThe primary purpose of patient

safety reporting systems is to learn from experience.

It is important to note that reporting in itself does not improve safety. It is the response to reports that leads to change.

◦ (WHO Guidelines for Adverse Event Reporting and Learning Systems, 2005)

Characteristics of Successful Reporting Systems (7)1. Non-punitive

◦ Reporters are free from fear of retaliation against themselves or punishment of others as a result of reporting.

2. Confidential ◦ The identities of the patient,

reporter, and institution are never revealed.

3. Independent ◦ The reporting system is

independent of any authority with power to punish the reporter or the organization.

4. Expert analysis ◦ Reports are evaluated by experts

who understand the clinical circumstances and are trained to recognize underlying systems causes.

5. Timely Reports ◦are analyzed promptly and

recommendations are rapidly disseminated to those who need to know, especially when serious hazards are identified.

6. Systems-oriented ◦Recommendations focus on changes

in systems, processes, or products, rather than being targeted at individual performance.

7. Responsive ◦The agency that receives reports is

capable of disseminating recommendations. Participating organizations commit to implementing recommendations whenever possible.

Safety WalkRounds

A “Safety WalkRound” is a process whereby a group of senior leaders visit areas of a health-care organization and ask front-line staff about specific events, contributing factors, near misses, potential problems, and possible solutions.

Can often result in prompt changes that improve care and safety.

It also can lead to culture change, as the concerns of front-line staff are addressed.

front-line staff are engaged in continuous observation of hazards and solutions for discussion with senior leadership.

Leadership walkrounds are a low-cost way to identify hazards of concern to front-line staff and make needed changes.

Require no additional staff, equipment, or infrastructure.

Failure Modes and Effects Analysis

Failure modes and effects analysis (FMEA) is a widely used tool for proactively identifying process vulnerabilities.

It begins by systematically identifying each step in the process and then searches out “failure modes”, that is, noticing what could go wrong.

The next step is to evaluate how the failure mode could occur, and what are the “effects” of this failure.

If a failure mode could result in catastrophic effects, the process must be corrected or buffered.

The FMEA is a proactive tool, used to evaluate a new process, or an existing process for proposed design changes.

Medication Admin Process Flow

- End-