Towards Zero Harm in the ED

Kylie Stark, Nurse Manager, SCH ED

Massive Challenge – Dynamic 24/7 Environment

To Err is Human

Institute of Medicine (2000): …as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention….

Why worry about patient safety?

Raj Behal 2014

• Because that’s what I want for those I love.

• Because none of us signed up to cause harm

• Because creating harm is the beginning of a ripple

• Because harm is expensive at every level.

Why Aim for Zero Harm ?

What is Harm ?

Harm: “Anything that impairs or adversely affects the safety of patients in clinical care, drug therapy, research investigations, or public health. Harms include adverse drug reaction, side effects of treatments and other undesirable consequences of health care goods and services”.

Adverse Event: “An incident in which harm resulted to a person receiving healthcare.” – many of these are preventable!Trust, respect, disappointment, anxiety – multiple costs

6

How much harm do we do ? We don’t really know !Table 6: Separations with an adverse event per 100 separations, public and private hospitals, 2011–12

Public hospitals Private hospitals Total

Separations with an

adverse event338,579 147,731 486,310

Separations with an adverse event per 100 separations

Same-day separations 1.8 1.4 1.6

Overnight separations 10.7 9.4 10.3

Acute care separations 5.9 3.7 5.0

Sub- and non-acute care

separations11.2 7.4 9.3

Emergency admission 8.9 11.9 9.1

Non-emergency

admission4.2 3.5 3.8

Total 6.1 3.9 5.3

Who do we Hurt?• Our Patients – 1 in 16 admitted pt in Australia experiences some kind adverse event

or near miss.( we don’t know what we don’t know)

• Our Staff – physical and psychological harm . Our workforce is at risk. ( we don’t want to know what we know)

Patient Story

This is Hannah and her family's story, in our care.

Mum here whole time with Hannah.

2yr old with Nana.

Dad away.

9

13:21 20:5624:00-08:00

08:00

Decision to admit with ? UTI

+/- tonsillitis on IV Gent and

Benpen

BNA- to stay in ED overnight

4/12 old presented to ED

with smelly urine and

fevers

HR in red and yellow zone

Fever YZ

? BNA in ED

Noted to have jerking movements

Noted to be mottled tachycardic

and tachypnoeic

RV by ED reg- bolus + cefotaxime

moved to acute area

09:10 09:30 ?15:00 17:10

In hospital bed meeting TL

asked why pt not transferred

to another hospital?

Admitting team contacted

“will review after ward

round’

Pt reviewed by admitting

team

Concerned re meningitis

and request ED to

complete LP

Dx likely meningitis

Pt improves and decision made to

transfer to MP4 hospital however

information not communicated to

parents by team

Issues for this patient and family

Diagnostic error

Recognition of the

deteriorating patient

CommunicationOwnership of the admitted patient in ED

What Harm do we Cause ?

• Wrong Diagnosis • Wrong Site/Side • Wrong Treatment or Test• HAIs• Failure to recognize deterioration

Why Does it Happen ?

In Emergency single biggest cause is

Congestion and Overcrowding

Boarding of Admitted Patients

Where is Risk ? Everywhere !

Why Else ?

Interruption

Communication

Human factors / HALT

Variation

Workload

Training/Competence

Lack of strong visible Clinical Leadership

Why is ED so Unique ?

We are Special in so many ways …………

• Concentrated environment of high risk behaviors

• consistent resources24/7 service without

• Communication challenges everywhere.

18

• Constant

• No control over flow in or out

• No influence over acuity or complexity

• Handover after handover after handover

• Environment

• Operations

• Cradle to Grave

Programs

Tools and Resources in Abundance ……

Systems and Processes to support and protect ..

IMMS

Clinical Reviews

RCAs

Checklists STILL NOT ZERO !!!!!!!!

Alerts

Evidence

Standards

CERS

Data Data Data – How can it help ?

KPIs – imposed on EDs

Performance is measured in time achievements. (RISK)

What data would help ?

Real time safety data.

How many imms and why ?

How many patients with high risk score ?

How many boarders and hrs ?

How many workforce and skills gaps ?

21

Where do you start in this journey ?

• At the top – the Leaders

• Understand your risk – IMMS/Complaints/Colleague feedback/Consumers/ evidence

• Engage your teams. Talk about the harm. Celebrate “good catches”

• How safe is your ED ? Do you know ? Publish the harm .

• How likely is it that harm will occur ?

What's New and Might help ?

Situation awareness – thanks to army/navy and airlines.

• Is everyone aware all the time ?

• Have updates occurred ?

• Have incidents been noted ?

• Has risk been escalated and mitigated where possible ?

• Is it safe for all staff to report risk ?

23

Huddles – short structured briefings.

They create

Psychological Safety.

They rely on a Teams that promote Trust and Respect

The Huddle

The Huddle

Bedside

nurse

Intern

Family

concerns

High risk

therapies

Watcher

Early Warning

Score ≥5

Communication

concern

Bedside

Team

Identify

Tested on 1 general pediatric unit

using Model for Improvement and

Plan-Do-Study-Act (PDSA) cycles

Bedside

nurse

InternWatchstander

Senior Resident

Watchstander

Charge Nurse

Family

concerns

High risk

therapies

Watcher

Early Warning

Score ≥5

Communication

concernAttending

Bedside

Team

Unit

Team

Identify Mitigate

Tested on 4

nursing units with

learning and

adaptations

Bedside

nurse

InternWatchstander

Senior Resident

Watchstander

Charge Nurse

Safety Team

(Nurse Manager

and Safety Officer)

Family

concerns

High risk

therapies

Watcher

Early Warning

Score ≥5

Communication

concern

Medical

Response

Team (MRT)

Attending

Bedside

Team

Unit

TeamOrganization

Team

Identify Mitigate Escalate

Tested on 4 nursing

units then spread

on 3/22/10

What helps ?• Workforce that matches workload

• Clinician driven local quality and safety programs

• Point of Care senior supervision

• KPI’s that reflect in the moment safety

• Risk measures that stop the clock

• Systems that support clinicians not data collection

ED at SCH

What do we do ?

Create awareness for EVERYONE

Huddle when situation changes

Investigate errors in the moment

Involve families

Encourage reporting

Listen

Are we safer ?

I don’t know ………

30

So in ED what is the solution?

A safety culture – What does it look like ?

Organizational engagement and response to ED capacity and risk

An educated orientated supported workforce 24/7

Hospital commitment to safe evidence based care and process

Clinical/Education support on the floor

Patient engagement – make them part of the team

My Dream

Risk identification at triage for every pt and then a risk score every hour that reflects acuity, workforce and patient load

Data sets that don’t require extra input but report real time risk

A score that electronically alerts the co-ord to changes in safety in the ED

Quite Simply ……..

Don Berwick

• Don’t kill me

• Don’t harm me

• Don’t do things that cannot help me

• Reliably do things that can help me

• Relieve my pain – physical and emotional

• Don’t make me feel helpless

• Share information

• Don’t make me wait

• Don’t waste money

What would you want for those you love?

Honesty

Trust

Respect

The Empathy Video

Thankyou.

36

Watch

Risky Business

TED talks

Share

Errors

Good catches

Celebrate

Your Staff