what is possible in a hospital getting to zero harm cincinati childrens story (É possível para um...
DESCRIPTION
Apresentação de Stephen Muething durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.TRANSCRIPT
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What Is Possible In A Hospital?
Getting To Zero HarmCincinnati Children’s Story
November 4, 2013
Stephen E. Muething, MDVice President for Safety
James M. Anderson Center
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SET THE GOAL
ACCEPT THE GAP
CONTINUOUS IMPROVEMENT
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Our Safety Goal:
ELIMINATE ALL HARM
Begin With Serious Harm
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Serious
Safety
Events
Serious Preventable
Events
Events of Minimal
to Moderate Harm
Near-Miss Events
Pyramid
of Harm
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BeganSituation Awareness
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High Reliability Organizations (HROs)
Kathleen M. Sutcliffe, MSN, PhD
Karl E. Weick, PhD
High Reliability OrganizationsEnvironment rich with potential for errors
Unforgiving social and political environment
Learning through experimentation difficult
Complex processes
Complex technology
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Characteristics of
High Reliability Organizations1. Preoccupation with failure
Regarding small, inconsequential errors as a symptom that something is wrong; finding the half-event
2. Sensitivity to operationsPaying attention to what’s happening on the front-line
3. Reluctance to simplifyEncouraging diversity in experience, perspective, and opinion
4. Commitment to resilienceDeveloping capabilities to detect, contain, and bounce-back from events that do occur
5. Deference to expertisePushing decision making down and around to the person with the most related knowledge and expertise
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Serious
Safety
Events
Serious Preventable
Events
Events of Minimal
to Moderate Harm
Near-Miss Events
Pyramid
of Harm
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75% Reduction
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80% Reduction
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0
2
4
6
8
1007
-05
260
0
09-0
5 2
43
3
11-0
5 2
25
4
01-0
6 2
00
2
03-0
6 1
73
4
05-0
6 1
98
3
07-0
6 2
33
2
09-0
6 2
35
5
11-0
6 2
43
2
01-0
7 2
33
0
03-0
7 2
60
4
05-0
7 2
55
6
07-0
7 3
20
7
09-0
7 2
60
3
11-0
7 2
57
4
01-0
8 2
46
4
03-0
8 2
22
4
05-0
8 2
79
2
07-0
8 2
78
6
09-0
8 2
44
7
11-0
8 2
33
5
01-0
9 2
66
7
03-0
9 2
83
5
05-0
9 2
37
0
07-0
9 2
92
4
09-0
9 2
62
5
11-0
9 2
51
4
01-1
0 2
42
1
03-1
0 3
04
5
05-1
0 2
89
2
07-1
0 3
21
4
09-1
0 2
79
0
11-1
0 2
74
1
01-1
1 2
87
1
03-1
1 3
11
1
05-1
1 3
27
4
07-1
1 3
75
6
09-1
1 3
55
2
11-1
1 3
58
3
01-1
2 3
44
4
03-1
2 3
69
5
05-1
2 3
99
4
07-1
2 4
28
3
09-1
2 3
50
4
11-1
2 3
67
4
01-1
3 3
46
2
Infe
ctio
ns
per
100
Pro
ced
ure
Day
s
Month of ProcedureProcedure Days
Infections
Surgical Site Infections by Procedure Date (Class I & Class II Combined)
Last Updated 02/14/2013 by K. Simon, Anderson Center for Health Systems Excellence Source: Surgical Safety Database
Q2/05 - Individual Anesthesia Follow-upQ3/05 - Anesth Compensation tied to complianceQ3/05 - Orange ID BraceletsQ4/05 - ABX In-pt ImplementationQ2/06 - CHG Wipes by All ServicesQ3/06 - Bundle Measure for Limited Ortho & Neuro
Desired Direction of
Change
40% Reduction
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HIGH
RELIABILITY
CULTURE
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Pre-Surgery Time-Out
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Huddles
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Increase Reporting
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Empowering to Stop the Line
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Frontline Leaders Owning Harm
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Peer
Observation
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THANK YOU!
QUESTIONS?
http://www.cincinnatichildrens.org/research/divisions/j/anderson-center/default/