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UCH Patient Safety

Tools For the Front Line

An Analysis of Human Factors and System Redesign

• Preventable DEATHS 44 - 98,000

• 2-20 errors/near misses per patient/day

• Only 1-10% errors reported

• Most are system flaws causing human error

• System flaws go unexamined unless there is concern for “significant” injury

• Preventable errors continue to occur

• Preventable costs $17 - 29 Billion

Current Climate in ‘Patient Safety’

In 2000, Upper Chesapeake Health initiated a system-wide Patient Safety Team

• Key Aims included:- Coordinating the Patient Safety Effort- Promoting a non-punitive culture- Develop and conduct organization-wide

assessment of safety practices (VHA tool)- Improving data collection and analysis of

adverse events and near misses

What UCH has Been Doing

Our Achievements• Developed and implemented the following:

- Patient Safety Plan , integrated system-wide- Centralized Patient Safety Committee - Departmental Case Study - a “process” review - The Good Catch - A proactive reporting component in the

online Event Tracking System- Departmental Risk Self-Assessments- Quality Council “Report Card” to track accomplishments of

department specific safety indicators- Track Performance Evaluation Scores for “Safety Standard”- Integrating patient safety initiatives into our existing

Rewards and Recognition program

What’s Next?

A Good Catch is reported when there exists hazardous conditions or a set of circumstances

that may lead to patient or injury,

if the process is left unchanged

Good Catch Reporting

The Case Study is designed as a teaching tool developed to broaden the frontliner’s understanding of, and practice with, a “process” review approach to error

… which in turn furthers efforts towards

a non-punitive safety culture

Case Study Program

• Obtain the Facts

• Present case to team

• Explore the Process(es) involved

• Brainstorm for opportunities to improve

• Develop an action plan with follow-up built in

Basic Principals

Frontliners can analyze or design processes that will be safe and effective

byunderstanding basic concepts of

human behavior

Human Error in Medicine

• Human Error is simply defined as an inappropriate or unintended act giving rise to an unintended outcome.

• The key however, are the circumstances that surround and impact the act.

Human Errors Occur Because of…

• Inattention

• Interruption

• Memory Lapse

• Communication failures

• Poorly designed equipment

• Environmental influences (lighting, noise)

• Knowledge deficit

• Fatigue

• Etc…

Principals of Human Errors

• Human Factors Engineering or Ergonomics

• Systems Analysis

• Cognitive Science

Human Error Defined Cognitive Concepts

• Slips, Lapses and Mistakes

• Skill based, Rule based and Knowledge based

The Freudian Slip

Slips and Lapses • Actions not in line with your intentions, execution

errors … hence the term “Freudian slip”

Mistakes • Resulting from a wrong plan of action triggered

by lack of knowledge, misinterpretation of the problem or bad habit.

Skills Rules and Knowledge

• Skills-Based = slips and lapses: You know what your doing, but the actions don’t go as planned

• Rules-Based = mistakes: You think you know what your doing, but fail to notice contraindications, apply a bad rule or fail to apply a good rule

• Knowledge-Based = mistakes: Your not really sure what you’re doing, lack of sufficient knowledge

Active and Latent Failures

When considering the human contribution to system failures distinguish between

Active and Latent Failure

• Active Failures occur immediately

• Latent Failures lie dormant until the surrounding circumstance trigger the failure

Humans vs. The System

• Characteristics of high risk processes that can lead to human failure

• Complexity

• Forced reliance on memory or vigilance

• Variable input / Inconsistency

• Human intervention

• Time constraints

• Hierarchical culture

A Path to Failure

Latent Current Active

Failures Conditions Failures DefensesACCIDENT

Cognitive Failures (Memory Lapses)

Slips

Mistakes

Workload

Equipment

Knowledge

Ability

Environment

Manufacture Design

Management Decisions

Policy

Faulty Process/System Design

Creates Circumstances Which Contribute to Human Error

Makes Errors Difficult to Detect

Makes Detected Errors Difficult to Reverse

What can be done….?

Failure Mode Effects Analysis

The FMEA is a systematic method of identifying and preventing process failures.

The FMEA is aimed at pre-event circumstances in an effort to predict and prevent injury caused by a system’s failure to support the human element.

Why FMEA?

FMEA examines a process to identify potential errors and determine possible effects. It is a team-based, systematic, proactive approach to identifying the ways a process or design…

…can fail

…why it might fail

…how it can be made safer

What is FMEA? Failure A System or Process performs in an undesirable

or unintended wayMode The ‘way’ in which the failure is caused to occur

(contributing factors)Effects The result or consequence of the failureAnalysis Detailed examination of the elements and structure

of a process

How to FMEA1. Identify what broke down, what steps failed…

Consider: - Human limitations - Equipment issues - Department interactions

2. Identify what could have prevented the breakdowns from occurring…Consider:

- fail-safes for human limitations

3. Identify what can improve the process… Develop: - an item by item action plan

The Key Is To Be Thorough!

7 Simple Steps in Applying FMEA

1. Select a Process2. Understand the Current Process

– Flow Chart by practice (not policy)

3. Identify Potential Failure Modes – List Causes (Contributing Factors)

4. Calculate Priorities of each Cause5. Develop Recommendations to Reduce

Reoccurrence6. Implement the Action Plan7. Measure your Success

When to Use the FMEA Case Study - Triggers

• ETS – Good Catch• Benchmarking industry

trends • Sentinel Event Alerts• Team Member

concerns• Patient Complaints• Patient Care – Near

Misses

• History of Adverse Events

• Literature identifies as High Risk

• Characteristic of High Risk Process

• New Process

• Proposed Redesign

Measure your SuccessYour Action Plan should• Include follow-up mechanisms, automate when able• Clearly define what, when and how to measure• Clearly define expectations and accountability• Clearly define reporting structure of various groups

Look to outside resources for assistance when you reach barriers

This shouldn’t be a burden, publicize your success and set backs to validate the effort….Stay the Course

Tools Available to You

Good Catch Reporting (ETS)

Case Study Program

Failure Mode Effects Analysis

Root Cause Analysis

And…

Healthcare Case Study FMEA

FMEA Table

Process Steps

Pain Assessment Process

Failure Modes 

Causes

Effects

Possibility1=remote

5=can occur10=certain to

occur

Severity1=no harm

5=may affect pt adversely10=injury or

death will occur

DetectionBefore event takes

place1=will always be

detected5=might be detected

10=detection not possible

Criticality(Mean of Poss,

Sev, Det)1=no action nec

5=action must be considered

10=action a must

Step 1: Assess Patient

FM: Inaccurate pain assessment C: Cultural influences Patient unable to

articulate Eff: Poor pain control

 

5 

5

 

5

 

5

Patient SafetyWe’re all in it together!

Recognize Human Factors and the Impact on Processes

Incorporate these Concepts into your Daily Routine

Utilize the Tools Available

Call on Resources such as the Risk Management Dept

UCH Service Standards

Safety, Courtesy, Efficiency and Environment