presentation at 2007 meeting of indian health service in san diego
DESCRIPTION
This is based on Jim Bagian's "Why Bother" (about patient safety) presentation. Jim was invited but had a conflict so I wen to the national meeting of the Indian Health Service. I think this was maybe a 75 minute presentation. I added some things to make it personal to me like the Jimi Hendrix Experience slide and slide 81 on the "tissue issue" in VA that I helped resolve during my work on hand hygiene improvement. The audience also seemed to like my closing slide.TRANSCRIPT
Patient Safety:Why Bother?
Noel Eldridge, MS for James P. Bagian, MD, PE
Chief Patient Safety OfficerDirector, VA National Center for Patient Safety
February 28, 2007
[email protected] & [email protected] www.patientsafety.gov
(Jimi couldn’t make it today. You got Noel.)
James Bagian, MD, PEDirector, VHA National Center for Patient Safety
Noel EldridgeExecutive Officer, NCPS
VA Statistics (FY 2005) 7.7M enrollees, 5.3M uniques VA Medical Centers (Hospitals): 156 Admissions: 587,000 Community Based Outpatient Clinics: 708 Outpatient Visits: 57.5M Rx Dispensed (30-day equiv): 231M Lab Tests: 215.9M Total FTE: 197,800
Veterans Health AdministrationVeterans Health Administration2211 Veterans Integrated Service Networks Veterans Integrated Service Networks
I J 2002
N ANUARY
W ERE INTEGRATED AND
RENAMED
VISN 13 14
VISN 23
S AND
Patient Safety Background and VA Information on Reporting
Institute of Medicine Goals
1. Safe – “avoiding injuries to patients from the care
that is intended to help them”
2. Timely
3. Efficient
4. Effective
5. Equitable
6. Patient-Centered (from Crossing the Quality Chasm, 2001)
NY Times and W. Post This Week
Medication Reconciliation & Adverse Events– “Unintentional drug poisonings accounted for
nearly 20,000 deaths in 2004, said the CDC, making the problem now the second-leading cause of accidental death in the United States, after automobile accidents.”
• W. Post – 2/27/07– “In August 2006, the Institute of Medicine of the
National Academies released a major study on medication errors in American hospitals that found that adverse drug events harm more than 1.5 million people and kill several thousand a year, costing at least $3.5 billion annually.”
• NY Times – 2/25/07
Where Healthcare Was/Is
Cottage Industry Mentality Virtually Total Reliance on:
– Professional/Individual Responsibility– Individual Perfection– Train and Blame
Little Understanding of Systems Relative to People and Processes– Ignorance vs. Arrogance
Culturally Different!!!!
Where Does a Culture of Safety Exist?
Would you agree to fly on a bankrupt airline to save $100?
Would you agree to get elective surgery at a bankrupt hospital to save $100?
Are your answers different? If so, why? Do you trust the airline “system” of
regulators, managers, pilots, and mechanics in a different way than you trust the healthcare “system”?
Sad Comment at amazon.com
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CAN YOU IMAGINE THE EQUIVALENT FOR AN AIRLINE TRIP?
NAVAL AVIATION MISHAP RATE
776 aircraftdestroyed in
1954FY 50-96FY 50-96
Fiscal Year
2.39
39 aircraftdestroyed in
1996
0
10
20
30
40
50
60
50 65 80 96
Angled Carrier DecksNaval Aviation Safety Center
NAMP est. 1959RAG concept initiated
NATOPS initiated 1961Squadron Safety program
System Safety Designated Aircraft
ACTHFC’s
Cla
ss A
Mis
hap
s/1
00
,00
0 F
lig
ht
Hou
rs
Three Important Questions
1. What Happened?
2. Why Did it Happen?
3. What Should We Do to Prevent it from Happening Again?
Typical Healthcare Approach
New Policies, Regulations,Reporting Systems, Training
Good First Step But…..
– Lack of Systems Insight
– Superficial Solutions (?Answers)
– Inadequate Follow-Up
– Lost Opportunity
Goal Selection Clear
– Not Confused With Tactics
Compelling– Relevance To Those Who Must Take Action
– Early Stakeholder Involvement in Goal Definition
Reinforced By Leadership– Visible Participation
• All levels – not hierarchical
Goal: Prevent Harm
VA Patient Safety Advisory - August 8, 2000
Item: Medtronic Dual Chamber Temporary Pacemaker model 5388
Specific Concerns: The Medtronic Dual Chamber Temporary Pacemaker model 5388 may become inactive if a button is touched while it is in "self test" mode. If this occurs the pacemaker display freezes, will not work properly and displays an error code of 0004. At this point the pacemaker cannot be turned off. In order to correct the situation the battery drawer has to be opened. Only removal of the battery clears the error and turns the pacemaker off. It may then be restarted.
Typical Missing Features
Clear Understanding of Goal
Preventive Approach
Field Understanding & Buy-In
Systems Approach
Sustainability
Trust/Culture of Safety
Safety System Design
High Reliability Organizations
Role of Reporting
– Learning or Accountability?
Systems-Based Solutions
– Patient Centered – DUH!!!!
Importance of Close Calls
VA Patient Safety Data & Feedback
Incidents reported have monotonically increased since reporting to NCPS started in 2000.
VA inpatient mortality down ~35% from 1999 to 2006. – (Remember: “Correlation is not causation.”)
VA Annual Events Reported (including close calls) is Still Going Up
Safety Assessment Code (SAC)Severity & Probability
Catastrophic Major Moderate Minor
Frequent 3 3 2 1
Occasional 3 2 1 1
Uncommon 3 2 1 1
Remote 3 2 1 1
The Value of Close Calls in Safety
Close calls can provide “sentinel” information without or before the “Sentinel Event.”
Patient Safety System Design
Patient Safety System Design
Most VA Reports are Actual “SAC 1s” (events with little or no harm, or close calls)
Which Events get RCAs?
Many RCAs are done on events that are not Actual 3s.
Numbers are surprisingly constant since 2001.
Is fewer actual SAC3s since 2001 & 2002 good news? Maybe.
RCA Categories (Coded by NCPS)
Selected Event (FY 2005) for Individual RCAs Percent
Fall 13.9%
Delay in Treatment/Diagnosis/Surgery 10.7%
High Alert Adverse Drug Events 10.5%
Unexpected Death 7.2%
Misidentification 6.3%
Missing Patient 4.9%
Hospital Acquired Infections 4.7%
Outpatient Suicide 3.4%
Correct Surgery 3.3%
65.0%
What about the Adverse Events and Close Calls that don’t get “RCAed”?
In VA Aggregated Reviews are performed at the local level, one per quarter on:
1. Adverse Drug Events
2. Missing and Wandering Patients
3. “Parasuicidal” Events
4. Falls– (When they are not “SAC 3” events)
Guiding Principles For Patient Safety System
Learning, Not Accountability SystemReporting System Characteristics
• Non-punitive - Confidential and De-identified• Internal and External
Importance of Close CallReports Should Emphasize Narratives Interdisciplinary Review TeamsAbout Identifying Vulnerabilities NOT
StatisticsPrompt FeedbackOpen to All Comers
What comes from RCAs?
1. Local Fixes and Learning
2. Local Insight into Better Methods for Improvement and the Tractability of Problems (not like the weather)
3. VA-wide Alerts and Advisories
4. Systemwide Learning and Informed policymaking
VA RCA data on Incorrect Surgical Procedures (2001 – 2005)
In-Operating Room: 33% Out-of-Operating Room: 42% Eye Procedures (can be either setting): 25%
What was Wrong? (2001-2005)
26 27
16
10
22
0
5
10
15
20
25
30
WrongPatient
WrongSide
WrongSite
WrongProcedure
WrongImplant
Per
cent
EXAMPLES…
Patient: Similar Diagnosis or NameSide: Other Side Similar DiagnosisSite: On Spine or Hand/WristProcedure:Biopsy vs. Cystoscopy Implant: Lens
VA RCA data on Retained Surgical Items, 2000-2005
Sponge, 52
Towel, 5
Other, 8
Human Factors and Strength of Actions
Safety & Human Error: Challenges
Healthcare Views Errors as Failings Which Deserve Blame - Fault
Train and Blame Mentality Blind Adherence To Rules Corrective Actions Focusing on
Individual No Blood No Foul Philosophy
Safety & Human Error:Cornerstones
People Don’t Come to Work to Hurt Someone or Make a Mistake
Must Keep Asking “Why?”
Safety – Human Error
Technical
IndividualTeam
Profession
Institution
Policies/ProceduresAccident
LATENT FAILURES
DEFENSES
Incomplete procedures
Regulatory narrowness
Mixed Messages
Production pressures
Responsibility shifting
Inadequate training
Attention Distractions
Clumsy Technology
Deferred Maintenance
Patient Safety - Strategy Invite People to Play
– Problem Recognition– Remove Barriers (Punitive, Difficulty, Black
Hole Effect)– Learning NOT Accountability System
Importance of Close Call Blameworthy Definition Training (Middle thru Top Management)
Leadership At All Levels Human Factors Approach
– Tools That Guide Behavior
Changing Culture
Tools
Behavior
Attitude
CULTURE!!!
Prioritize
Risk Based– Severity– Probability
Must Make Sense– Business Processes– Regulatory Environment
Systematic
Cause and Effect Human Error Must Have Preceding
Cause Failure to Follow Procedure By Itself Is
NOT a Root Cause Negative Descriptors Aren’t Actionable Failure To Act Is not Cause Without
Pre-existing Requirement To Act Why,Why,Why
Causation/Actions:Who vs.What &Why
Who– ‘Whose Fault Is This?’– Actions focused on correcting individual– ‘Corrects’ only after problem occurs– Limited scope of action and generalizability
What & Why– Actions focus on systems level causation– Widespread applicability– Stronger preventive strategy
Intentionally Unsafe Acts
“…events that result from: a criminal act; a purposefully unsafe act; an act related to alcohol or substance abuse by an impaired provider and/or staff; or events involving alleged or suspected patient abuse of any kind.”
Intentionally Unsafe Acts are off-limits to Patient Safety (RCA) review, everything else is within limits
On Being Human
Behavior Response
When I say “up”, everyone raise your hand as quickly as you can
This was not an aerobic exercise
Demonstrates: “paired associate learning”
Medical Software Correlation
- Pharmacist uses 95% of time.- “Enter” button enters data.
- Pharmacist uses 5% of time. - “Spacebar” enters data.
“Take-away” on Human Factors…
Considering and acting on knowledge regarding human capabilities, limitations, and tendencies when designing and operating devices and systems
Not always “common sense”
Human Factors Engineering and “Actions”
Warnings and labels (watch out!)
Training (don’t do that)
Procedure changes (work around that)
Interlock, lock-in, lock-out, etc (let me design it so you can not do that – forcing functions)
Is there one right action???
Weaker
Stronger
Actions & Interventions
Stronger Actions
Architectural/physical plant changes New devices with usability testing before purchasing
Engineering control or interlock (forcing functions)
Simplify the process and remove unnecessary steps Standardize on equipment on process or caremaps
Tangible involvement and action by leadership in support of patient safety
Intermediate Actions
Redundancy Increase in staffing/decrease in workload Software enhancements/modifications Eliminate/reduce distractions (sterile medical
environment) Checklist/cognitive aid
Eliminate look and sound-alikes Readback Enhanced documentation/communication
Weaker Actions
Double checks Warnings and labels
New procedure/memorandum/policy Training Additional study/analysis
Strong Action: Brake and Automatic Transmission Connection
“Simple” Engineering Solutions at Disneyworld Resorts (Motels)
Simple Engineering Solutions at Disneyworld Resorts (Motels)
Now I need a car roof that’s round!
Blue tubing does not fit here or here…it only fits here
Alert based on “wrong-tube” RCAs Veterans Health Administration Warning System Published by VA Central Office AL06-012 April 6, 2006
– Item: Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions
– Specific Incidents: Since 2001, VA facilities have reported five cases of accidental infusion into an IV line or PICC line. Amphotericin B (Attachment #1) was given intravenously when it was intended for irrigation of the bladder via a catheter. The same adverse event could occur with Glycine. Amphotericin B and Glycine are both contraindicated in patients with kidney or liver disease and when Amphotericin B is infused via IV line, it can induce serious complications (e.g., kidney failure).
Look-alikes (different “eye-drops”)
Sound-alikes (e.g., Flomax and Flonase)
Redundancy vs. Double-check in Spelunking (Caving)
Two choices of equipment
1. One flashlight batteries checked twice
2. One flashlight and one headlamp
Lawnmower cut-off switch
Experience is an Expensive Teacher
Management Involvement
Formalized, Not Ad Hoc Safety Permeates the Fabric of All
Activities Relentless
Safety System Design
Action AssessmentAssessment
Characteristics of Actions– Temporary vs. Permanent– Procedural vs. Physical
Action Evaluation– Process– Outcome
Business Case for Patient Safety
Is There A Business Case?
YOU BET!!! Examples:
– “Easy CAP” CO2 Detector
• $154/detected esophageal intubation– RCA/40person-hrs X 12RCA/yr
• 0.25FTEE
Devices to prevent Out-of-OR Esophageal Intubations are Cost-Effective
Description Equation =
Numerator Cost to implement (11,000 [# of codes] x $10)
$110,000
Denominator Number of recognized events (assuming 100% prevention effectiveness)
715
Cost-Effectiveness Measure
$110,000 / 715 $154
InterpretationIt will cost $154 to detect one unanticipated esophageal intubation ($10 per use at a rate of 6.5%)
Benefit-Cost of Patient Safety
National Center for Patient Safety, Regional Patient Safety Officers, Facility Patient Safety Managers, Local RCA teams
~$130k per VA Medical Center (0.1%)
If this is a VA facility’s budget
This is Patient Safety’s Share
Some Interventions have Zero CostUse of Antimicrobial Soap in VAMCs
43
1938
3 16
81
0102030405060708090
Use AntimicrobialSoap Only
Use Non-antimicrobial
Soap Only
Use Both Typesof Soap
Perc
en
t (N
=~120)
Dec-03
May-04
See Hand Hygiene Tools on www.patientsafety.gov
Summary and Wrap up
Sustainable Systems Approach Problem Identification Clear Goal Definition Involvement Of All Sectors Identify Systems Influences Identify Systems Controls Identify Constraints Critique – Go To Worst Critics Early On Pilot – Volunteers First Then Others Evaluate
Critical Elements
Safe for Reporters/Participants Prioritization Method What is Blameworthy Not About Fault – 3 W’s Human Factors Engineering Tools
– Triage Cards, RCA Method Concur/Not Concur (Mgmt/Leadership) Feedback Dedicated Patient Safety Duties
Closing Thoughts
Not About Errors!!! Counting reports is not the objective,
identifying Vulnerabilities is– Hope they increase
–Analysis, Action, & Feedback are the key
Prevention NOT Punishment Cultural change is the key – takes time
Safety is the Foundation Upon which Quality is Built
Safety as the Foundation? Quality programs can ensure that we use
evidence-based medicine to determine which cardiac patients…– Are prescribed the most appropriate of many
medications, and/or– Get angioplasty with or without drug-eluting or
bare metal stents, and/or– Get CABG surgery
But if they get surgical site and/or urinary tract infections, and/or fall in the hospital…– Can you call this High Quality Care???
Why Bother?
1. The Problem is Real2. You Can Do Things to Make it
Better
“They say that time changes things, but you actually have to change them yourself”
Andy Warhol
Recently we have received a number of questions about whether is it legal to buy facial tissues. At issue is whether or not the facial tissues are considered personal items.
We have discussed this issue with Department logistic and financial staff as well as VHA clinical staff.
The following provides a basis for the decision that was reached: For patient-care areas and areas frequented by those who come in direct contact with patients, facial tissues should be considered similarly to other expendable supplies that VA workers may use as they perform their duties during work hours. For example, VA supplies disposable respirators, gloves, and surgical scrubs and gowns, all of which are employed by staff to protect patients from the spread of infectious agents. This type of expenditure is clearly appropriate. On the second point, recent guidance from the CDC, JCAHO, the National Health Information Center of the Department of Health and Human Services, and the American Lung Association have all included recommendations for using tissues to cover coughs and sneezes to prevent the spread of infectious agents. First among these infectious agents are viruses that cause upper respiratory infections such as cold and flu, but another agent of concern is Staph. aureus (SA), including methicillin-resistant SA (MRSA), either of which can cause skin and wound infections. Various estimates put the percentage of healthcare workers whose nasal passages are colonized with SA at about 30-40%. (The percent colonized by MRSA is not well described and seems likely to vary widely.) SA and MRSA can be expelled from the nose during a sneeze and live for days or weeks on substrates such as clothes, linens, curtains, countertops, and other environmental surfaces where they can be picked up on hands or transferred to other surfaces and eventually patients. Using a tissue to reduce the dispersion of droplets and the gross contamination of hands or clothes is imperfect but is widely recommended as a basic measure to control the spread of infectious agents.
Conclusion: Facial tissues to be used in patient care areas and areas frequented by those who come in direct contact with patients can be purchased with appropriated funds. This memo should not be taken as a mandate
to generate any new requirement to provide tissues in specific locations or at any pre-set density. Decisions on this topic should be made locally and incorporate local circumstances and considerations.
(Agreed upon by: Fiscal, Accounting, Legal, Network Clinical Managers, Public Health, Environment of Care, Infectious Diseases, Patient Safety, in about 3 weeks.)
Are we there yet?
“From a certain point forward there
is no longer any turning back. That
is the point that must be reached”
- Franz Kafka
Have a Safe Trip Home!
San Diego