patient safety – it takes a village, but it starts with you! · patient safety – it takes a...
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Patient Safety –
It Takes a Village…..
but it starts with You!
JoAnne Phillips, DNP, RN, CPPS
Manager of Quality and Patient Safety
Penn Homecare and Hospice Services
Patient Safety Journey
History
IOM
Safety Culture
High Reliability
Hippocrates 4th Century BC
◦ First Do No Harm
ASHRM
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“It may seem a strange principle
to enunciate, as the very
first requirement in a hospital
that it should do the sick no harm”
Florence Nightingale, Notes on Nursing, 1869 ASHRM
Do No
Harm
4th cent
1855
Semelweis
Hygiene
Practices
1960s
ICUs
1980s
APSF
1991:
Harvard Medical
Practice Study
98,000 People Die from medical
Errors.
Half Preventable
1. Prevent errors
2. Learns from errors
3. Build on culture of patient
safety that involves hc
organizations,
professionals and patients
2001
Crossing
Quality
Chasm
2002
NPSG
2004
WHO
2004
Transforming
Work Environment
Of Nurses
2005
PSO
2008
CMS: No
Pay for
Bad care
2009
$19 bill Health IT
Lit synthesis
IOM Roundtable
Pres. Advisory
2010
Patient Protection
and Affordable
Care Act
2005
100,000
Lives
5 mill
Analysis of
mortality
data
Nightingale
1863
ASRM; James; Jha & Pronovost
IOM…1999
It must be
better by
now… right?
5 years
• Improvements
• Reporting
• Leadership
• Gaps
• IT
• Accountability
10 years
• Improvements
• Reporting
• Malpractice
• Gaps
• Regulatory / accreditation
• HIT
• Workforce training (Wachter, 2004; Wachter, 2010)
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Betsy Lehman
Dana Farber
1995
2007
Quaid Twins
Kimberly Hiatt
The people –
the devastation……
Jessica Santillan
2003 2011
Julie Thao
2009
Nora Bostrom
Patient Safety Impact on Mortality….
Going in the Wrong Direction
2008
• 11th leading cause of death
2013
• 3rd leading cause of death
Adverse Events: 2005 - 2011
Medicare All patients
by 8% / year for MI
by 8% / year for CHF
No change in pneumonia
No change in post-op complications
2010: 145 AE / 1000 hospitalizations
CLABSI, CAUTI, Falls, PU, ADE
2014: 121 AE / 1000 hospitalizations
◦ 16.5% improvement
2.1 million fewer harms
$$$$$ BILLIONS saved
Kronick
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Adverse Events
Decrease 4.5% year –
◦ Sounds great, right?
By 2025
◦ We would have half as many AE as we had in 2010
◦ WAY too slow…..
Are you willing for your family member to be the one who…
Falls? Develops a CAUTI? A CLABSI? Post Op complication?
Objectives
Describe the patient safety journey
◦ Where have we been… we are we going….and why is it taking so long to get there?
Relate the concepts of a patient safety culture with high reliability organizations
◦ Do you work in a highly reliable organization?
Discuss the role of the NURSE in creating and sustaining a safety culture and moving toward high reliability
◦ Just Culture
◦ QSEN competencies
Patient Safety Journey
History
IOM
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient Centered
Safety Culture
• Just Culture
High Reliability
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INSTITUTE OF MEDICINE
Health Care
Safe
Effective
Pt. Centered
Timely
Efficient
Equitable
Patient Safety Culture
Foster a Learning
Environment
Evidence based
practice
Healthy Work
Environment
Decreased risk for adverse
outcomes
Barnsteiner
A way of thinking, behaving, or working in a place / organization
Patient Safety Culture
• Minimize the risk of harm to patients and providers through system effectiveness & individual performance
Goal of Patient Safety
Barnsteiner
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Culture of Patient
Safety
Teamwork
Transparency
Accountability
Empowerment
EB Learning
Leadership
Blousing & McDonagh; Hebling &Hewe; Hughes
AONE Guiding
Principles in
Patient Safety
Patient Safety
Lead Cultural
Change
Provide Shared
Leadership
Build External Partnerships
Develop Leadership
Competencies
Patient Safety Culture: What does it look like?
Trust
• Peers and leaders
Report
• Errors
• Near misses
• Risk
• Recognize & reward
Improve
• Unsafe conditions
Accountability
• Human error
• Willingness to disclose error
AONE; Blousing & McDonagh; Chassin & Loeb; Hebling &Hewe; Hershey; Hughes
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Role of Nursing Leadership in Creating a Culture of Patient Safety
Knowledge, tools &
resources
Executive Leadership
Workforce knowledge: zero defects
Engage pts / families
Culture of Safety survey
Transparency in reporting and feedback
Safety should be a design
element
Audit / monitoring
plan
Safety awards
Patient Safety Culture
Burgendahl, Hebling & Huwe
Empowered
Be heard
Feel Important
Stop the Line…..
Examples of Stop the Line
• Hand hygiene violation
• Wrong site surgery
• Medication administration
Patient Safety Culture
Teamwork is a requirement to work in this organization
Burgendahl, Hebling & Huwe
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Subcultures in a Patient Safety Culture
Reporting Culture
Just Culture
Flexible Culture
Learning Culture
AORN; Hughes
Just Culture
“an environment where professionals believe they
will receive fair treatment if they are involved in an
adverse event and trust the organization to treat
each event as an opportunity for improving safety”
Patrician, et al, 2016
Just Culture Behaviors
Human error -inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. ◦ Misreading of blood sugar value, administer wrong coverage
At-risk behavior –behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified. ◦ Skip independent double check
◦ Do not participate in the time out
Reckless behavior -behavioral choice to consciously disregard a substantial and unjustifiable risk ◦ Refusing to do OR count
◦ Coming to work under the influence
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Just Culture Accountability
Behavior Managed Through
Human errors: slips, lapse, or
mistakes
Processes, procedures, training and
design: Console
At-Risk Behavior: a choice – risk not
recognized or believed justified
Removing incentives for at risk
behavior and creating incentives for
health behavior and increasing
situational awareness: Coach
Reckless behavior – a conscious
disregard of unreasonable risk
Remedial action or punitive action:
Punish
Outcome engineering
Just Culture: Examine these 2 cases
Independent Double Check Independent Double Check
Sam is a very experienced CC nurse. His
patient was on norepinephrine and the bag
needed to be changed. Everyone was busy,
so he did not get an IDC. At change of shift,
it was noted that the infusion was the
wrong concentration and he was giving the
patient half the dose he thought. No harm,
no foul.
Marie’s patient was receiving a dilaudid
infusion on the PCA pump. Marie did not get
an IDC, she didn’t think she needed it.
Because her patient’s dose was half (wrong
concentration), he went into a pain crisis
and needed extra IV doses of Dilaudid and
Ativan to get under control.
Behavior = Same
Outcomes = Totally different
Management = Should be the same
Are these cases different ?
Application of Just Culture
Leadership rounding
Employee recognition
Transparent communication about reported patient safety events
Mentoring and coaching
Fair and just accountability principles
Gathering feedback from employees
Patrician, et al, 2016
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Build External Partnerships
Academia
Technology
Communities
Policy Makers
Regulatory Agencies
Professional Organizations
Patient
AONE
Culture of Safety: How do we measure?
Required by Joint Commission
◦AHRQ survey
◦VHA
◦Westat
AHRQ Culture of Safety Survey
Culture of Safety Survey
◦Non-punitive response to error
◦Handoffs and transitions
◦ Staffing
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Non-punitive Response to Error
Fair and reasonable response to error
Punishment for slips, lapses, mistakes: have no impact
DO NOT focus on the outcome, but focus on the behavior
Behaviors
◦ Human error – action that cannot be reduced by punishment
◦ Negligence – should have been award of the risk, but failed to exercise
expected care
◦ Intentional rule violation – conscious violation of safety rule
◦ Reckless conduct – conscious disregard of substantial and unjustified
risk
Handoffs and Transitions:
A Time of Vulnerability Transition: patient moves from one care setting to the next
Handoffs: the communication between health care workers during these
transitions
Up to 80% of serious medical errors may be related to
miscommunication during handoff
◦ Information is omitted 30-40% of the time
◦ Incorrect information is shared 13% of the time
Hershey
Handoffs and Transitions: Vulnerability
Handoffs
◦ Shift reports that are pre-populated with pertinent data from the EMR
◦ Structured formats for report, such as SBAR or PACE
Teamwork: Key to handoffs and transitions
◦ Poor communication (intimidating and disruptive behavior) can undermine
safety Refusing to answer pages, staff not calling to clarify an order because of fear they will be “yelled
at”
◦ Zero tolerance for disruptive behavior
Hershey
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Safe Staffing
Increased adverse events with:
◦ Insufficient staffing
◦ Excessive workloads
◦ Worker fatigue Immune system, metabolism, cardiovascular system, and impair judgment
◦ High turnover
Joy and meaning of work necessary to transforming a
safe culture
Hershey
Patient Safety Journey
History
IOM
• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient Centered
Safety Culture
• Just Culture
High Reliability
Goal: High Reliability
What is high reliability?
Organizations that achieve and sustain high levels of safety
despite high potential for serious events to occur
Chassin and Loeb; Hershey; Latney
Wrong site
surgery:
50 times/week
OR Fires:
600 times/ year
HAI
200 deaths /
day
75,000 year
Airlines: 1 major injury / 3.1million flights
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HRO Principles
Preoccupation with failure
◦ Heightened awareness of risk
◦ Proactive and preemptive analysis and discussion of risk
◦ Looks for abnormalities, recognize defects
Reluctance to simplify interpretations
◦ Question assumptions
◦ Investigate all levels of risk with the same intensity
Blouin & McDonagh; Hughes; Latney
HRO Principles
Sensitivity to operations
◦ Situational awareness
◦ Understand the frontline work to prevent errors
◦ Awareness of broad risks
Commitment to resilience
◦ Cope with, contain, and bounce back from adverse events
Deference to expertise
◦ When attempting to solve a problem, the decision making migrates to the person who has the most expertise, regardless of the level of authority or rank.
◦ Organizations can respond more quickly to unanticipated events
Blouin & MCDonagh: Hughes; Latney
HRO in Healthcare
Leadership must commit to a goal of zero preventable harm
HRO principles must be integrated with the organization to
develop a culture of safety
The organization must adopt a rigorous process improvement
program to improve the quality of care and outcomes
Chassin & Loeb; Latney
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HRO Outcomes High Reliability in Health Care:
◦ Improves organizational effectiveness
◦ Improves organizational efficiency
◦ Improves customer satisfaction
◦ Improves compliance
◦ Improves organizational culture
◦ Improves documentation
Competencies to Improve
Quality and Patient Safety
Patient Centered Care
◦ Decisions based on patients values, beliefs, and preferences
◦ Patient / family are treated with respect
◦ Partners in care
Teamwork and collaboration
◦ How well teams work together
◦ Nurses need skills in problem solving, conflict resolution, and negotiation
◦ Emotional intelligence
Barnsteiner
Competencies to Improve
Quality and Patient Safety
Evidence based practice ◦ Best evidence available
◦ Spirit of inquiry
Safety ◦ Minimize the risk of harm to patients and providers
◦ Assess system effectiveness vs individual performance
Informatics ◦ Thread through all competencies
◦ Documentation in the EMR, with decision support and safety
alerts
◦ Retrieve the best evidence, manage QI data Barnsteiner
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AONE Leadership Competencies
Culture of Safety Competencies
Core Patient Safety
Technology Competencies
Public Safety Leadership
Competencies
= Practice
environment
of safety
AONE
Obstacles to a Safety Culture
Healthcare is complex and inherently risk prone
system Tolerance of individualistic practices
View errors as failures and assign blame
Focus of training is on rules versus knowledge
Punish individuals… don’t address the system
If no injury, no action
◦ Outcomes should not influence response
Fear of retribution for reporting
Organizational lack of ownership for patient safety
Hughes
Strategies… Start Now
Simplify and standardize
workplace, equipment, supplies
and processes
Establish constraints that
encourage and drive medical
professionals to do the right
thing
Reduce reliance on memory
Foster robust communication
between stakeholders
Conduct training
Plan interdisciplinary team training programs
Managers and leaders continually contribute to the process of improving quality
Culture of fairness and Accountability
Monitor and evaluate errors
Implement methods to reduce errors
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So much to do…. Where to focus?
Eliminate unnecessary, unreliable metrics
Develop standardized / validated metrics
Use clinical, not administrative data
Where to Focus?
Adverse drug events
Hospital acquired infections
◦ Only one with validated clinical data
Venous Thromboembolism
Pressure Ulcers
Falls
Surgical Complications
Top Patient Safety Strategies…
Pre-Op / anesthesia checklists
Bundles to include checklists to prevent central line infection
Decrease the use of indwelling urinary catheters
Preventing pneumonia and other infections in people on
ventilators by elevating the head of the bed, sedation vacation,
subglottic suctioning, oral care with chlorhexidine
Washing hands
Shekelle, Pronovost, et al.
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Top Patient Safety Strategies…
Avoiding the use of abbreviations for medications or
procedures
Simple strategies for preventing pressure ulcers
Gloves, gowns, and other barrier precautions to prevent
healthcare-associated infections
Using ultrasound to guide the placement of central lines
Treatment and prevention efforts blood clots in a leg, arm, or
lung (venous thromboembolism)
Shekelle, Pronovost, et al.
Safety Strategies
Skilled communication
True collaboration
Effective decision making
Appropriate staffing
Meaningful recognition
Authentic leadership
Healthy Work Environment
What does this mean
to your practice? Questions?
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Patient Safety: Takes a Village
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