introduction to the science of improving patient safety
TRANSCRIPT
Introduction to the Science of Introduction to the Science of Improving Patient Safety, Just Improving Patient Safety, Just
Culture and Safe Patient Handling & Culture and Safe Patient Handling & MobilityMobility
Dennis Jones, DNP, RN, NREMT-PSafety & Quality Officer
Lifeline Critical Care Transport TeamJohns Hopkins Hospital
Instructor – JHUSON
Learning ObjectivesLearning Objectives
• To recognize that every system is designed to achieve the results it gets
• To identify the basic principles of safe design that apply to both technical and team work
• To discuss how teams make wise decisionsTo identify the basic purpose of a Comprehensive Unit - based Safety Program (CUSP) team
The content for the above objectives from Department of Patient Safety – Johns Hopkins Hospital. Used with permission.
• To discuss the rationale for, and identify components of, Safe Patient Handling & Mobility (SPHM) Interprofessional National Standards
• Identify a variety of assist devices to be used in SPHM.
The problem of keeping patients safe The problem of keeping patients safe is large is large
In U.S. Healthcare system• 7% of patients suffer a medication error• Every patients admitted to an ICU suffer adverse
event• 44,000- 98,000 deaths• $50 billion in total costs
• Similar results in UK and Australia
Kohn To err is human
The image of Patient Safety for JHHThe image of Patient Safety for JHH Josie King – 18 months old
• Admitted to JHH January 2001 after suffering 60% BSA (2nd degree, or partial thickness burns)
• Josie stayed in JHH PICU from admission to just before Valentines day when she was moved to IMCU.
• Pt developed vomiting, and diarrhea, confirmed CLABSI. Placed on oral Antibiotics (no IV access) and eventually became dehydrated, lethargic and unresponsive. Treated with Narcan, and Josie was allowed to drink (1 liter of fluid). Methadone was d/c’d.
• Per mom, Josie continued to look bad, and a pain specialist thought she should return to PICU but attending surgeon said no. Pain specialist recommended ½ original dose of methadone to prevent withdrawal. 1 dose of oral Methadone given. Pt went into cardiac arrest, resuscitated for long period. Was brain dead and removed from life support on 2/22.
How can such an event happen?
• People are fallible• Medicine is still treated as an art, not science• Need to view the delivery of healthcare as a
science• Need systems that catch mistakes before they
reach the patient
How Can We Improve?How Can We Improve?Understand the Science of SafetyUnderstand the Science of Safety
• Every system is perfectly designed to achieve the results it gets
• Understand principles of safe design – standardize, create checklists, learn when things go
wrong
• Recognize these principles apply to technical and team work
• Teams make wise decisions when there is diverse and independent input
Caregivers are not to blameCaregivers are not to blame
Case studyCentral line removal•A woman with metastatic cancer was hospitalized in theintensive care unit (ICU) for management of congestive heartfailure and acute-on-chronic renal failure. The nephrology serviceinitiated continuous venovenous hemodialysis through alarge-bore catheter inserted in the right internal jugular vein.Two weeks later, a first-year renal fellow removed the catheterwhile the patient was seated upright in a chair. The patientbecame acutely hypoxemic and appeared to seize. Head imagingrevealed global central nervous system ischemia suspiciousfor hypoperfusion. The patient survived but had neurological deficits and died about 6 months later.
SystemSystem FailureFailure LeadingLeading toto ThisThis ErrorError
Catheter pulled withPatient sitting
Communication betweenresident and nurse
Lack of protocol For catheter removal
Inadequate trainingand supervision
Patient suffers
Venous air embolism
8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.9. Reason J, Hobbs A., 2000.
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System Factors Impact SafetySystem Factors Impact Safety
HospitalHospital
Departmental FactorsDepartmental Factors
Work EnvironmentWork Environment
Team FactorsTeam Factors
Individual ProviderIndividual Provider
Task FactorsTask Factors
Patient CharacteristicsPatient Characteristics
InstitutionalInstitutional
10. Adapted from Vincent C, Taylor- Adams S, Stanhope N., BMJ, 1998.
Principles of Safe DesignPrinciples of Safe Design
• Standardize – Eliminate steps if possible
• Create independent checks
• Learn when things go wrong– What happened– Why– What did you do to reduce risk– How do you know it worked
Standardize - Line Cart Contents Standardize - Line Cart Contents
Eliminate StepsEliminate Steps
Create Independent ChecksCreate Independent Checks
Principles of Safe Design Apply to Principles of Safe Design Apply to Technical and Team WorkTechnical and Team Work
Basic Components and Process of Basic Components and Process of CommunicationCommunication
16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.
Teamwork ToolsTeamwork Tools
• Staff Safety Assessment• Daily goals• AM briefing• Shadowing• Barrier Identification and Mitigation• Learning from Defects
Systems Systems
• Every system is designed to achieve the results it gets
• To improve performance we need to change systems
• Start with pilot test one patient, one day, one provider, one RN, one room
Comprehensive Unit-based Safety Program (CUSP) Comprehensive Unit-based Safety Program (CUSP) An An Intervention to Learn from Mistakes and Improve Safety CultureIntervention to Learn from Mistakes and Improve Safety Culture
1. Educate staff on science of safety http://www.hopkinsmedicine.org/quality_safety_research_group/
2. Identify defects
3. Assign executive to adopt unit
4. Learn from one defect per quarter
5. Implement teamwork tools
Timmel J, et al. Jt Comm J Qual Patient Saf 2010;36:252-260.
RecapRecap• Accept that we will make mistakes• Develop lenses to see systems and design to make
them safer• Value the wisdom of frontline staff• Work to standardize one process• Infuse these principles of standardization and
independent checks in other processes• Recognize culture is local• Seek to expose (not hide) defects• Don’t play man down
– Speak up when you have a concern– Listen when others do
SPH&M“The incidence rate of back injuries among nurses is more than
double that among construction workers, perhaps becausemisperceptions persist about causes and solutions.”
Nelson, A.; Fragala, G.; Menzel, N. (2003). Myths and Facts About Back Injuries in Nursing. American Journal of Nursing. 103(2), 32-40.
“A healthcare professional is the only professional who considers 100 pounds, light”.
“If you have a 300 pound container in a warehouse that needs to be moved, how is it done?” – forklift
“If you have a 300 pound patient in a hospital that needs to be moved, how has it traditionally been done?” – you get more people.
D. Jones
SPH&M
• Manual handling/lifting of patients• How much can (should) we lift? • What are barriers to not manually
handling/lifting of patients?• What are the potential negative outcomes to
manual lifting?• So what do we do about it?
SPH&M – ANA Interprofessional National Standards
1. Establish a culture of safety
2. Implement and sustain a SPH&M program
3. Incorporate ergonomic design principles to provide a safe environment of care
4. Select, install, and maintain SPHM technology
5. Establish a system for education, training, and maintaining competence6. Integrate Pt-centered SPHM assessment, plan of care, and use of SPHM technology7. Include SPHM in reasonable accommodation and post-injury return to work8. Establish a comprehensive evaluation system
Examples of SPHM technology
Maxi-Move lift Maxi-move with patient
Examples of SPHM technology
Maxi – Sky ceiling lift Maxi – Sky ceiling lift with patient
Examples of SPHM technology
• Kreg Bariatric E-Z Wider bed:
http://kreg.us/VideoArchive/EZWider/full/EZ2.7/index.cfm
• Air assisted lateral transfer device
Conclusion
• Be aware of systems issues as you go through nursing school
• Think safety, for the patient AND you.• Take the time to get help, appropriate
equipment when moving patients• Get involved in safety & quality committees
initiatives within your organization