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