WRHA Regional Integrated Patient Safety Strategy

MCHP Need to Know Session

October 17, 2005

Regional Integrated Patient Safety Strategy

1. Why?

2. What is RIPSS?

3. Who?

4. When?

Patient Safety: Definition

• The reduction of preventable harm to patients

• Reduction• Preventable• Harm

• (prevention, detection, mitigation)• concept of “Getting to Zero”

PS 101: The Problem

• Institute of Medicine (1999) To Err is Human:• 44,000-98,000 preventable deaths in hospitalized

patients each year in US

• 90,000 deaths/year from nosocomial infections (CDC, 2002)

• 218,000 deaths/year from preventable ADE’s (2004)

• 21 preventable deaths/hour in US (2005, IHI)

PS 101: What About Canada?

• Baker and Norton (2004, CMAJ) Canadian Adverse Event Study

• 3,700 charts of patients hospitalized in 2000 reviewed• 7.5% of patients experienced an adverse event• 1.6% of hospitalized patients experienced an adverse event and

died• 500 bed hospital will have almost 100 preventable adverse

events/ month

• almost 2 deaths/hour

PS 101: What about Canada?

• 2 patient deaths/hour due to healthcare system failure excludes:

• Psych, obs, paeds, LTC, continuing care, residential and PCH care and all ambulatory care

• In other words, 2 patient deaths/hour hugely underestimates the impact of patient safety challenges

WRHA RIPSS – Why?

• CCO reporting and management policy: 2002

• 2004: first full calendar year of data collection

• Retrospective analysis of acute care CCOs• Comparison to Baker/Norton • No chart review• Assess WRHA’s ability to learn from CCOs and spread

to facilities and programs

Breakdown of Acute Care CCO’s

• CCO’s 174

• Deaths34

• Our current capacity does not support knowing how many were preventable

9

11

24

561614

44

Medication

Surgery

Diagnosis

Falls

Med Eqpt.

L&D

Other

21%

5%

7%

32%

35%

No Review

Site Individual

Site Team

Regional

Stan/PPCO

Review Type

Overall, 67% of our status reports were “late”, i.e. >40 days

Event (CCO)

CDP’s

Contributory Factors

Recommendations

Team Factors

Work Environment Factors

Organisational & Management Factors

Individuals (staff) Factors

Patient Factors

Task & Technology Factors

Institutional Factors

“Blunt end vs. Sharp

end”

Forcing functions, checklists, safety huddles, education, vigilance, retraining

London Protocol

Event Review Process: The London Protocol

The Results of our Process

37%

63%

CDP'sIdentifedNo CDP'sIdentified

17%

83%

C-Factors

No C-Factors

Results of ReviewWhat Works in Patient Safety

Forcing functions

Constraints Redundancy Standardization Simplification

Education Vigilance Exhortation

Most Effective Least Effective

CCO Recommendations

45%

38%

17%

Systemic(Blunt)

Education(Sharp)

NoRecommendationsto PreventRecurrence

How are we Doing?(Baker/Norton’s Projections for WRHA)

• AE’s/yr 4400• Highly preventable AE’s/yr

1600• Deaths associated with highly

preventable AE’s/yr 80

*Numbers based on 100 AE’s/month/500 beds; again, excludes psych, obs. and peds.

WRHA Integrated PS Plan

Four main components:

1. Promoting culture change2. Direct involvement of patients and families3. Learning from clinical practice:

• RCA retrospective analyses• FMEA prospective analyses• Trigger tools

4. Promoting change in direct care delivery

WRHA: RIPSS

Promoting culture change

• Executive walkrounds• Safety surveys (staff)• Safety huddles• Safety briefings• PS simulations• Developing a just and fair culture• Preventable deaths on the agenda• Patient faculty presentations• PS week activities• Campaign re catching PS butterflies in the safety net• “Ever kill someone with your bare hands?” campaign

WRHA: RIPSS

Direct involvement of patients

• Formation of provisional PSAC• Broadening of Speakup program• Creation of town hall series• Expansion of PSAC to other sites• Safety focus groups and surveys post patient discharge• PS resource centres at sites• Project specific working groups• Patient faculty for health sciences student presentations• PS “patient visitors” program

WRHA: RIPSS

Learning from Clinical Practice

• CCO/disclosure policy revisions• Refine CCO processes – notification, analysis, spread• Establish “P&Q” committee • P&Q to “close loop” on CCO recommendations• Further training of London protocol CCO analysis technique• Development of PS SWAT team methodology• Identify “preventable deaths”• Promote FMEA in sites• “Safety net” (NM – good catch) methodology• Active surveillance strategies

WRHA: RIPSS

Promoting change in Care delivery

• MedRec as regional SHCN! project • Support specific SHCN! initiatives• Support med safety initiatives• Implement and evaluate CCO recommendations• Launch falls prevention strategy with targeted pilot• Culture change in targeted community hospital research• Healthcare CRM initiatives• Communication (SBAR) techniques to build teams• Development of PS simulation centre

WRHA: RIPSS – Who

• WRHA PS Team now:• Robson/Kilpatrick/Sidorchuk/Thomas/Pelletier

• WRHA PS Team soon:• Leader in Human Factors• Leader in Applied Learning• PS Consultants (CCO Review Specialists) (2)• CCO Coordinator (P&Q Committee)

• WRHA PS Team next year…..

WRHA: RIPSS – Who Else?

“Ask not what your RHA can do for you,

Ask what you can do to advance the cause of patient safety in your region, through your facility”

- JFK

WRHA: RIPSS – When?

Hope is not a plan.

Soon is not a time.

- Don Berwick

(at least 2 patients/hour die in Canada as a result of a healthcare system failure)

Comments or questions?

Contact Info:

Dr. Rob Robson

Chief Patient Safety Officer, WRHA

204-926-7075

rrobson@wrha.mb.ca