evolution and transformation of patient safety in to the modern health care system tools &...
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Evolution and transformation of Patient Safety in to the Modern Health Care System- Tools & TechniquesPresented by Krish Sankaranarayanan MS, MBA, CPHQ
Senior Safety Officer
Tawam Hospital. UAE
Introduction-About me
• Been in healthcare domain for over 24 years.• Triple Masters degree.• MS in Patient Safety Leadership from UOI- Chicago.• Certified Professional in Healthcare Quality (CPHQ)• Educational consultant- Canadian Healthcare
Association- CQI progarm• Membership
– Member American College of Healthcare Executives– Member National Association of Healthcare Quality – Member American Society for Healthcare Risk Management – Member American Society of Professionals in Patient Safety– Vice President of the ACHE Middle East and North Africa Group
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Disclosure
The presenter has nothing to disclose, nor has any commercial interest with any of those information's displayed in this presentation.
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About Tawam Hospital
• Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in the middle of the desert, and one among the largest healthcare facilities in the United Arab Emirates.
• In 2006 the General Authority of Heath Services now called as the Abu Dhabi Health Services Company PJSC (SEHA) entered in to a ten year affiliation contract with Johns Hopkins Medicine.
• Tawam Hospital has current status with • Joint Commission International Accreditation (2006; 2009; 2012), • College of American Pathology (CAP; 2011) and • American College of Graduate Medical Education- International (ACGME;
Program Accreditation)
I will………
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Items for discussion
• Ice breaker– Video: Capt. Chesley "Sully" Sullenberger
• Historical context of Patient Safety• Lessons from high reliability organization • Patient Safety definitions• Patient Safety Organizations• Why do errors happen?• Second Victim• Tools & techniques to improve patient safety
Capt. Chesley "Sully" Sullenberger- Video
Hippocratic Oath
5th century BC -Physicians and other healthcare professionals swearing to practice medicine honestly
Florence Nightingale The founder of modern nursing
1863-“the very first requirement in a Hospital is that it should do the sick no harm
Dr. Ernest Codman
1905 started "end result idea.“ Hospital standardization. Doctors should follow up with all patients to assess the results of their treatment and that the outcomes actively be made public.
How is it that aviation became safer than healthcare ???
High Reliability Organizations
Zero compromise to safety
The Annual Toll of Medical Injury IOM “To Err is Human” (1999)
• 44,000 – 98,000 deaths/year in US due to medical errors.
• $ 50 billion in total costs.• 7% of patients suffer a medication error.• Every patient admitted to ICU suffers an
adverse event.
1 in 3 people say that they or a family member has experienced a medical error at some point in their lives
180,000 people die each year due to iatrogenic injury in US.This is equivalent to three fully loaded jumbo- jet crashing every two days.
Most of it where preventable !!!!
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10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
Tota
l liv
es
lost
pe
r ye
ar
REGULATEDDANGEROUS(>1/1000)
ULTRA-SAFE(<1/100K)
Health Care
Mountain Climbing
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
Why do errors happen in healthcare?
Miscommunication- Video
That killed him- Video
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National Quality Forum List of Never Events-28
• Unintended retention of a foreign body in a patient after surgery or other procedure
• Surgery performed on the wrong body part• Surgery performed on the wrong patient• Wrong surgical procedure performed on a
patient• Infant discharged to the wrong person• Stage 3 or 4 pressure ulcers acquired after
admission to a healthcare facility
The patients saw an average of 17.8 health professionals during their hospitalization
National Patient Safety Goals Established in 2003
Established in 2001
Anesthesia Patient Safety Foundation launched in late 1985
APSF was incorporated as an association in July 1989
World Alliance for Patient Safety was launched in 2004
Canadian Patient Safety Institute Established in 2003
National Patient Safety FoundationEstablished in 1997
What is Patient Safety?- Definition
• The freedom from accidental injury due to medical care or from medical error.(Institute Of Medicine)
• The prevention of healthcare errors, and the elimination or mitigation of patient injury caused by healthcare errors. (National Patient Safety Foundation)
• The absence of the potential for or occurrence of health care associated injury to patients. Created by avoiding medical errors as well as taking action to prevent errors from causing injury. (Agency for Healthcare Research and Quality)
The biggest hurdle!!!!!!
Reported errors
Not reported
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We Name, Shame & Blame people
“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”(Leape 2009)
Dr. Lucian Leape is a professor at Harvard School of Public Health, he is a health policy analyst whose research has focused on patient safety and quality of care
Second Victim- Eric Cropp story (Video)
Eric Cropp story (Video)
Common Response After a Medical Error
The types of suffering are • Increased anxiety about the future possibility of
errors.• Loss of confidence in the work they do.• Some face difficulty sleeping.• Concern about their reputation as a care giver • Reduction in their sense of job satisfaction.• Excellent clinicians may leave the profession
prematurely when involved in a preventable error.
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Medical error: the second victim..
• The term second victim was initially coined by Wu in his description of the impact of errors on professionals. The doctor who makes the mistake needs help too.
• In the aftermath of a mistake, it's important the doctor seek support to deal with the consequences.
Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MD
System Failure Vs Individual Fault
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“Insanity: doing the same thing over and over again and
expecting different results”Albert Einstein
Avedis Donabedian
1966 –Structure leading to Process and process leading to Outcome Whether a procedure or intervention has made a favorable difference.
Structure Process Outcome Paradigm
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“Every system is perfectly designed to achieve the results it gets.”
Donald Berwick, M.D.President & CEO of Institute for Healthcare Improvement
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Not Bad people - But Bad Systems
Medical Errors related Behavioral Choices
RecklessBehavior
Intentional Risk-Taking
Manage through: • Remedial action• Disciplinary action
At-RiskBehavior
Unintentional Risk-Taking
HumanError
Product of our current system design
Manage through changes in:
• Processes• Procedures• Training• Design• Environment
Console Coach Punish
Manage through:
• Removing incentives for at-risk behaviors
• Creating incentives for healthy behaviors
• Increasing situational awareness
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How do we prevent errors?
Errors can be prevented by designing systems that make it hard for people to do the wrong thing, and easy for people to do the right thing.
Critical thinking & System redesign - video
Critical Thinking - Video
System Redesign- Video
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System Design- Forcing Function
Steps to Minimize Medical Error
Forcing functions & constraints
Automation & computerization
Standardization & protocol
Checklist & double check system
Rules & policies
Education/ Information
Be more careful, be vigilant
Mosteffective
Leasteffective
Tools & Techniques To prevent medical errors &
Improve patient Safety
Accreditation programs Seeking gold standards
National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India
JCIA- Standards
1. International Patient Safety Goals (IPSG)
2. Access to care and continuity of Care (ACC)
3. Patient and Family Rights (PFR)
4. Assessment of patients (AOP)
5. Care of patients (COP)
6. Anesthesia and Surgical care (ASC)
7. Medication management and use (MMU)
8. Patient and Family Education (PFR)
9. Quality Improvements and patient Safety(QPS)
10.Prevention and Control of Infections (PCI)
11. Governance Leadership and Direction (GLD)
12.Facility Management and Safety (FMS)
13.Staff Qualification and Education (SQE)
14.Management of communication and Information (MCI)
Patient Safety Goals
1. Identify Patients Correctly2. Improve Effective Communication3. Improve the Safe Use of Medications4. Ensure correct-site, correct-procedure,
correct- patient Surgery5. Reduce the Risk of Health Care –Associated
Infections6. Reduce the Risk of Patient Harm Resulting
from Falls
Goal 1Identify Patients Correctly
Use two identifiers Patient full name, DOB, Medical Record # etc
• Before giving medication• Before administering blood or blood products • Before taking blood samples & specimens • Before doing clinical testing • Before providing any treatment or procedures
Correct Patient Identification
Do Not Use
Patient Room Number or Location
to identify the patient
NO Room #
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Use of technology
Goal 2Improve Effective Communication
• Effective communication, which is timely, accurate, complete, unambiguous, and understood by the recipient, reduces errors and results in improved patient safety.
Miscommunication- Video
The German Coast Guard
Improve Effective Communication
• Verbal & Telephonic order– Write down and “Read- Back”
• Communicate critical test results– Write down and “Read- Back”
• Use of SBAR, I PASS BATON- structured form of communication
• Daily Goals Checklist
Verbal & Telephone orders
Daily Goals Check List
Bridging the hierarchy challenges
Goal 3Improve the Safe Use Of Medications
• Following the Seven Rights• Storage, labeling and segregation of
High Alert Medication• Do Not Use dangerous abbreviation
List• Medication Reconciliation
Seven rights to prevent medication errors
• RIGHT drug• RIGHT patient (Two Identifiers)• RIGHT dose• RIGHT time• RIGHT route• RIGHT reason• RIGHT documentation
Improve the Safety of High-Alert Medications
HIGH ALERT MEDICATIONS :- Drugs that bear a heightened risk of
causing significant patient harm when they are used in error. Although mistakes may or may not be more common with these drugs, the consequences of an error with these medications are clearly more devastating to patients.
(Institute for Safe Medication Practice)
Storage, labeling and segregation
• Concentrated Electrolytes are removed from patient care areas unless clinically necessary
• Segregated from other medications and Labeled as "High Alert
Concentrated electrolytes are: Magnesium sulfate injection Potassium Acetate injection Potassium chloride for injection concentrate Potassium phosphates injection Sodium Acetate injection Sodium bicarbonate 8.4% injection Sodium Chloride for injection, hypertonic (greater than 0.9% concentration) Sodium Phosphate injection
Storage, labeling and segregation
Independent Double Checking- Video
Independent double check
Medication Reconciliation
• Obtain information on the medications the patient is currently taking
• Medication orders are compared to the list of medications taken prior to admission
The Medication Use System
Selection & ProcuringEstablish formulary
Monitoring Assess patient response to drug; report reactions & errors
AdministeringReview dispensed drug order; assess patient & administer
Preparing & DispensingPurchase & store drug; review & confirm order; distribute to patient location
PrescribingAssess patient; determine need for drug therapy; select & order drug
Clinician & administrators
Physician/ prescriber
Pharmacist Nurse/other health professionals
All practitioners, plus patient &/or family
Joint Commission. 1998
Major Areas for Medication Error
Prescribing
Transcribing
Dispensing
Administering
38% 39%
12% 11%
Medication Errors Reporting Program US
Prescribing Errors
Contributing factors:• Illegible handwriting• Inaccurate medication history taking• Confusion with the drug name• Inappropriate use of decimal points• Use of abbreviations• Use of verbal order
Williams DJ. 2007
Prescribing Errors….. Example
Name That Drug…
Lipitor 10mg PO QD
Filled Rx: Zyrtec 10mg
Prescribing Errors….. Example
Name That Drug…
6 units of regular insulin now
Filled Rx: 60 units
Prescribing Errors….. Example
Name That Drug…
Tegretol 300mg BID
Filled Rx: Tegretol 1300mg
Dispensing Errors
• Selection of the wrong drug• Similar appearance or similar
name (look alike sound alike medication)
Dispensing Errors…..Example look alike sound alike
Dispensing Errors…..Example look alike sound alike
Administration Errors
Contributing factors:• Failure to check the patient’s identity
prior to administration • Storage of similar preparations in
similar areas • Noise, interruptions, & poor lighting
Williams DJ. 2007
Systems & Technology to prevent medication errors
Tall man lettering to prevent look alike sound alike drugs
Computerized Physician Order EntryCPOE- with decision support system
Automated drug dispenserBarcode Scanner
bedside medication verification
Smart Infusion pumps
Goal 4Ensure correct-site, correct-procedure, correct- patient Surgery.
• Use a checklist.• Verify all documents. • Check equipment needed for surgery.• Mark the precise site ( involve the
patient ).• Use "time-out" just before starting a
surgical / invasive procedure.
WHO Safe Surgical Checklist- Video
How to perform a “Time-Out”
Goal 4Reduce the Risk of Health Care –Associated Infections
• Strict hand hygiene before and after contact with each patient or their environment
• Adequate hand hygiene facilities for staff and patients
• A clean hospital environment and good hygiene practice
• Isolation of patients in single rooms, when necessary, to reduce the risk of infection
• Careful prescription of antimicrobial drugs• Training on infection prevention and control for all
staff
Five moments of hand hygiene
Technology support
Sharps disposal box
Hand sanitizer dispenser
Antimicrobial Stewardship
• Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs.
• The Infectious Diseases Society of America (IDSA)
Healthcare Associated Infection- HAI
• Central line Associated Blood Stream Infection- CLABSI
• Surgical Site Infection-SSI• Cather Associated Urinary Tract
Infection-CAUTI• Ventilator Associated Pneumonia -VAP
HAI
• CLABSI – Attributable mortality: 9-25% – Attributable cost: $25,000-$45,000– Of patients who get a bloodstream infection from having a
central line, up to 1 in 4 die.• CMS Medicare and Medicaid no longer pays hospital
for CLABSI • CLABSI
– Remove Unnecessary Lines – Wash Hands Prior to Procedure – Use Maximal Barrier Precautions – Clean Skin with Chlorhexidine – Avoid Femoral Lines
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Replicating the same for CLBASI Free Days
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NNU CLABSI Free Days
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PICU CLABSI Free Days
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ICU CLABSI Free Days
CUSP Team with the ICU Executive - COO
Dangerous enviornmentSpread of infection- Video
Goal 6Reducing the risk of patient resulting from fall
• Falls account for a significant portion of injuries in hospitalized patients.
• Establish fall-risk reduction program– Initial assessment of patients for fall risk
during admission– Reassessment of patients when indicated
by a change in condition or medications– Implemented fall reduction strategies – Monitor intended and unintended
consequences of fall risk measures
Epidemiology of inpatient falls
• 1235 falls by 1082 pts (3.10 falls/1000 pt days)
• 89% single fall, 11% more than once• 40% related to toileting• Serious injury (laceration requiring sutures,
loss of consciousness, fracture, SDH) – 6%• Death – 0.2% (both in patient with more than
1 fall)
Source: Inf Control Hosp Epidem 2005;26:822
Falls risk assessment tools
• Morse, STRATIFY, Hendrich II
Prevention strategies to reduce patient fall- video
Fall Prevention Strategies
Place fall precautions sign in patient’s room. Communicate fall risk during hand-off of care Maintain bed in low position, and put bed rails up. Assess hourly patient’s need for toileting. Actively engage patient and family Lock all moveable equipment before transferring patients. Do not leave patient unattended for transfers/toileting. Place patient care articles within reach (call bell, urinal, phone,
water). Provide physically safe environment (adequate lighting,
eliminate spills, clutter, electrical cords, and unnecessary equipment).
Evaluate medication profile for fall risk. Move patient closer to the nursing station for those at High Risk
Fall prevention protocols
“If you can’t measure it, you can’t manage it.”
Peter Drucker
Key Performance Indicators (KPIs)
• Embrace the following :– People – staff focus– Service – customer focus– Quality – excellence in clinical
outcomes and service– Finance– Growth – expansion of
services
Dashboards
• Powerful graphs communicating both the financial and nonfinancial key performance indicators
• Designed to translate vision & strategy into objectives
• Employees can:– embrace, achieve,
measure & celebrate.– focus on annual goals &
long term strategic goals.
Color Coded Dashboard
Discussions- The End Game
Are these initiatives sufficient to prevent & eliminate Medical Errors and improve Patient Safety?
If not……then how do we get to the ideal situation??
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Building a Culture of Safety
How to integrate SAFETY in to the CULTURE of the organization???A CUSP Approach
Topic of my next lecture will be
I will………
Resources-websites
• http://www.iom.edu/ • http://www.npsf.org/ • http://www.ihi.org/explore/patientsafety/pages/default.aspx • http://www.hopkinsmedicine.org/armstrong_institute/ • http://www.josieking.org/ • https://www.patientsafetygroup.org/main/index.cfm • http://www.pso.ahrq.gov/ • http://www.patientsafety.gov/ • http://www.safetyleaders.org/
References
• How many health professionals does a patient see during an average hospital stay? N Whitt, R Harvey, S Child
• Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467–76.
• Rossheim J. To err is human—even for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21 Jan 2009).
• Green, M.J., Farber, N.J., and Ubel, P.A. Lying to each other. Archives of Internal Medicine, 2000;160:2317-23.
• Mizrahi, T. Managing medical mistakes: ideology, insularity and accountability among internists-in-training. Social Science & Medicine, 1984;19(2):135-46
• Hickson, G. B., Clayton, E. W., Githens, P. B., et al. Factors that prompted families to file medical malpractice claims following perinatal injuries. JAMA, 1992;267:1359-63.
References
• Vincent, C., Young, M., and Philips, A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet, 1994;343:1609-13.
• Witman, A. B., Park, D. M., and Hardin, s. B. How do patients want physicians to handel mistakes? A survey of internal medicince patients in an academic setting, Archives of Internal Medicine, 1996;156(22):2565-69.
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Patient Safety Top PriorityPatient Safety Everyone's Responsibility
Contacts:Email- [email protected]
Mobile- +971 50 9211649
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