Hello!IamKris.SanbornMillerwithSafetyFirstNursingandthisisSafeMedica.onAdministra.on:Everythingyouneedtoknowtoimproveyourprac.ce.Ihaveprovidedthismoduleinmul.pleformats.Youcanwatchthisvideo,listentothepodcastandreadthepowerpointwithaGachednotes.IstartedSafetyfirstnursingbecauseIwasn’tfindinganynursingpodcastsforcon.nuingeduca.oncredit,soIhopethisbenefitsyou.AliGlebitaboutme:Iamacer.fiedpa.entsafetyprofessionalwithover10yearsofnursingexperience.Iwasapa.entsafetyofficerforahospitalinthesoutheasternUS,andIamcurrentlyworkingonmydoctorateinnursing.Mydisserta.ontopicstudiestheeffectofRootCauseAnalysisonNursingknowledgeandaRtudesofsafemedica.onadministra.on.Inaddi.on,IjustgotbackfromtheNa.onalPa.entSafetyCongress,whichwasincredible,andIamproudtosaythatwhatIampresen.ngyouiscongruentwiththevisionoftheNPSF,whichistokeeppa.entsfreefromharm.AnotherreasonyoushouldchooseSFNisthatIdonate10%ofallmyprofitstoalocalnonprofit.IambasedinAshevilleNCandsupportConsiderHai..IamworkingwiththemtosendayoungHai.anwomantonursingschool.Pleaselookforaddi.onalpodcasts,blogsandlearningac.vi.esfocusedonHai.,mobileclinics,andmyexperiencesthere.

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Youmayhavealreadybeentomysite,butifyouhaven’tandyouwanttoearncon.nuingeduca.oncreditforthismodule,gotosafetyfirstnursing.comwhereyoucanpayforthecourse,fillouttheevalua.onandreceiveacer.ficateforcon-edapprovedbytheNorthCarolinaNursesAssocia.on,anaccreditedapproverbytheAmericanNursesCreden.alingCenter’sCommissiononAccredita.on

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Thismoduleisbroughttoyoubysafetyfirstnursing,whichsupportsthephysical,psychologicalandemo.onalsafetyofpa.entsandnursesthrougheduca.on,resourcesandresearch.YoucanfindmeatSFN.com,ontwiGer,facebook,andlinkedin.MywebsitehaslinkstoconsiderHai.aswellasalltheresources,references,handoutsandinforma.oncontainedinthispresenta.on.Iwouldlovetohearfromyouaboutthispresenta.on–feedbackisinvaluable,andletmeknowwhatothertopicsyouareinterestedinlearningabout.Shootmeanemailatsafetyfirstnursing@gmail.comtoletmeknowwhatyouthink.Thankyouforpar.cipa.ng,Iamlookingforwardtomanymoreinterac.onswithyouasIcreatecuRngedgenursingeduca.onfocusedonpa.entsafety.

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Duringthispresenta.onwewillexplorethehistoryofmedicalerrorandthedevasta.ngeffectmedicalerrorhasonnotonlythepa.ent,buttheproviderandthehealthcareorganiza.on.Wewilltalkaboutthepossiblelossofjob,money,.me,energy,andpoten.allongtermphysicalandpsychologicaleffects.Thereisthisideainnursingthatifwejusttryhardenough,wewon’tmakemistakes,butweDO–infact,errorisactuallyinevitable;howeverHARMisNOT.Nursesspendabout40%ofour.meadministeringmedica.ons–anditismedica.onerrorthatisthemostcommonmedicalerror.Infact,Itisunlikelyyouwillgetthroughyourcareerwithoutmakingatleastonemedica.onerror.Thispresenta.onwillshowyouthateventhoughweareboundtomakemistakes,beinghumanandall,therearethingswecandotoreducetheriskofmakingamistake.Bytheendofthismodule,youwillhavemanytoolsforreducingyourriskofmakinganerror.

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TheIns.tuteofMedicinepublishedareportin2000called“ToErrisHuman”(Kohn,2000).Thisreportisbasedonthousandsofchartreviewsfromvarioushospitalsinthelate80”sand90’s.Americanswereshockedtofindoutthatmedicalerrorkillsthesamenumberofpeopleasifajumbojetfullofpassengerscrashedeveryweek,withnosurvivors.Whatisevenmoreshockingisthatthesenumbersaretoolow!Doctorstendnottoreporterrors,anderrorsfromoutpa.entseRngsarenotcollected.Since2000,effortstochangethesenumbershavebeenongoing,withmixedresults.In2004theAgencyforHealthcareResearchandQuality(anexcellentsafetyresource)studyreported195000deathsperyearbetween2000and2004.In2008,thesurgeongeneralreported180,000deathsfromMedicarepa.entsexperiencingmedicalerror.Somees.matesputthedeathratefromerrorat1.13%.Ifyouappliedthatratetoallhospitaladmissionsin2013,thenthetotalis400,000deaths.ThisisjustINPATIENTCARE.RecentresearchsuggestsmedicalerroristhethirdleadingcauseofdeathintheUS.InareportfromtheBri.shJournalofMedicinein2016,theauthorstalkabouthowdeathfrommedicalerrorisnotincludedondeathcer.ficatesbecauseitdoesn’thaveanICD10code.Theauthorsanalyzehowmedicalerrorfitsinwiththeleadingcausesofdeath(heartdiseaseandcancerares.ll1&2)withlowerrespiratorydiseasebeing3rdandaccident4th.(Makary&Daniel,2016).Thegoalisforpa.entstobefreeofharm–specificallypreventableaccidentalharm.Wecannoteradicatehumanerror,butwecanbuildsafeguardswhereweknowerrorislikely,therebydecreasingtheimpactoferrors

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Ayoungwomanrecoveredwellanerasuccessfultransplantopera.on.However,shewasreadmiGedfornon-specificcomplaintsthatwereevaluatedwithextensivetests,someofwhichwereunnecessary,includingapericardiocentesis.Shewasdischargedbutcamebacktothehospitaldayslaterwithintra-abdominalhemorrhageandcardiopulmonaryarrest.Anautopsyrevealedthattheneedleinsertedduringthepericardiocentesisgrazedthelivercausingapseudoaneurysmthatresultedinsubsequentruptureanddeath.Thedeathcer.ficatelistedthecauseofdeathascardiovascular.Itillustrateshowapa.enthasclearlydiedfrommedicalerror,yetduetothewaythedeathislisted–it’snotdetectableasacauseofdeathbytheCDC(Makary&Daniel,2016).

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ThisslideisfromawonderfulbookbyRobertWachtercalledUnderstandingPa-entSafety(2012).Medicalerrorterminologycanbeconfusingduetooverlappingandconflic.ngterminology.Alladverseevents(ADE)orharmresultinmorbidityandmortality,inotherwords,diseaseordeath-sufferedasaconsequenceofunderlyingmedicalcondi.on.TheIns.tuteforHealthcareImprovement(IHI)definesanADEasunintendedphysicalinjuryresul.ngfromorcontributedtobymedicalcarerequiringaddi.onalmonitoring,treatment,hospitaliza.onordeath.Hereiswhereitgetsconfusing–notallADEarepreventable.Thosethatareconsideredpreventableareeventsthatoccurredbyanactofcommissionoromission(doingsomethingwrong,failingtodotherightthing)leadingtoanundesirableoutcomeorsignificantpoten.alforsuchanoutcome–asinthecaseofthewoman’sdeathfromaccidentalnickingofherliver.Someofthesepreventableeventsareduetonegligence–prac.cethatfallsbelowthestandardofcare,thuscrea.nglegalliabilityordutytocompensate.Sothecaseofthewomanwhodiedfromanickedliverfallsintothecategoryofnegligencewhenwediscoverthatthesurgeonhasahistoryofthesetypesofevents.Studiesofcasesofharminhospitalizedindividualsfindabout50%tohavebeenpreventable(Landrigan,2010).Non-preventableeventsoccurintheabsenceoferror(likeacceptedcomplica.onsofsurgeryormedica.onsideeffects).Butthereiscontroversyhereaswellbecausethingsweusedtothinkofasnon-preventablelikeCentralLineAcquiredBloodStreamInfec.on(CLABSI)havebeenshowntobepreventablewithconsistentuseofevidencebasedprac.ce.Ul.mately,

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HereisanexamplefromWachter(2012)tohelpillustratetheterms:Apa.entiscorrectlyprescribedWarfarinforchronicatrial-fibrilla.on,andsubsequentlydevelopsaGIbleed.Bleedingisconsideredasideeffectofwarfarinifthepa.enthadatherapeu.cINR–thehospitalwouldconsidertherisk/benefitsofprescribingwarfarin,andlookatthescience–anynewdrugsonthemarketthatdon’thavebleedingasasideeffect?Ifthepa.entdevelopsaGIbleedandtheINRis3.5,it’sconsideredpreventable,butnotanerrorbecausethehospitalandDr.werefollowingprotocols.Whattheyneedtodoislookatistheprotocols–istheINRbeingcheckedonenenough?Aswellascheckingrisk/benefitandscien.ficstrategies.Considerthechangeinperspec.veifthephysicianhadprescribedthepa.entCrestor,asta.nknowntointeractwithwarfarin–thephysiciandidn’tlookupthedruginterac.ons,andthehospitalsystemdidn’tcatchthemistake–theteamlookingatthiserrorwouldnowlookatchangestoorderentrywithsomedecisionsupporttocatcherrors.NegligencewouldbeifthedoctorknowinglyprescribedCrestor,orhadprescribedCrestorinthepastwiththesameresult.Manyerrorsoccurthatdon’treachthepa.ent.Anearmissexamplewouldbethatthepa.entwasprescribedwarfarinforchronicafib,andasupra-therapeu.cINRwasdiscoveredBEFOREanyGIbleedingdeveloped.TheDosagewasadjustedandthepa.entdevelopednoGIbleed.Askyourself–wouldthisbereportedasanerror?Andiftheansweris“no”,howcanwelearnfrommistakesifwedon’tknowaboutthem?

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Oneoftheotherdifficul.esofdiscussingmedicalerroristheconceptofmeasurement.Beforeyoucansetouttochangesomething,youhavetodecidehowtomeasureimprovement.Solet’sconsiderhowerrorismeasured.Self-reportismostcommon,viaincidentreports,whichusedtobepaperandpencil,butnowareincreasinglyonline.Interes.ngpointhere,nursestendtousethem,butdoctorsdonot.Thesereportsarevoluntary,whichcanleadtoconfusionaboutwhatcons.tutesimprovement.Let’ssayaunitusuallyhas100reportspermonth,butanerarecentpushtoimprovesafetyculture,includingencouragingpeopletoreportandevidencethatincidentreportsarebeingreadandactedupon–incidentreportsincreaseto200permonth.DoesthismeanthereareMOREerrors?Orthattheerrorsareactuallybeingreported?Thereisnowaytoknowifself-reportisyouronlymeasurementtool.Luckilythereareotherways.InastudybyFlynnof36hospitals,Atrainedpharmacistconfirmedthatofthe2556dosesofmedica.onadministered,457wereerrors(about20%).TheyhadRNs,LPNsandpharmtechsusethreedifferentmethodstomeasuretheerrorrate.Directobserva.onofanursegivingmedica.onsdetectedanerrorrateof11.7%(300errors).Chartreviewdetectedanerrorrateof0.7%(17errorsdetected).Andincidentreports?Youguessedit-therewas1–givinganerrorrateof0.4%.InanotherstudybyKiekkasin2011,clinicalevidencefrom6differentdirectobserva.onstudieswasreviewed,thedifferenceswereevenmorestartling:“true”errordetectedbydirectobserva.onwas65.6%.Chartreviewyieldedanerrorrateof3.7%.Selfreportgaveanerrorrateof0.2%.Atissueisthatchartreviewanddirectobserva.onareexpensiveand.meconsuming.Inaddi.ontothesemethods,thereisalsotheglobaltriggertool(GTT)whichuseschartreviewoftriggerslikesuddentransfertoanotherunit,orprescribingbenadryltosignalanerrormayhaveoccurred.Someerrorstriggeraresponsethatcanbetracked.GTTisBestusedasascreenduetothecostin.meandmoney.Otherwaystomeasureerrorincludeusinghospitalstandardizedmortalityra.os,measuringAHRQpa.entsafetyindicators(theyhavelisted25atthis.me)andaskingpa.entstoreporterrors

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Somees.matethatmorethanonemedica.onerrorperdayoccursforeachhospitalizedpa.ent(Aspden,2007),butonsequencesarewhatreallymaGer.Let’skeepinmindthatnotalladverseeventsareequal–wearemoreconcernedwiththosethatcauseharmordeath.Theundeniableimpactisonpa.entsandfamilymembers.Wachter(2012)reportsthat1/8ofMedicarepa.entsexperiencesignificantAdverseDrugEventsduringhospitaliza.on.TakealookatthePropublicapa.entsafetycommunityFacebookpageortheMedicallyInducedTraumaSupportSystem(MITSS)websitetoseetheimpactofmedicalharm.Thereisnostandardplacetogotogethelpwithdealingwithemo.onal,financialandphysicalimpactofharmfromerror.SomeoftheconsequencesofADEinclude:hospitaladmissionorreadmission,increasedcomplica.ons,psychologicalharm,suchasangerordepression;economicharm,suchaslostpayorextendedstay.Thesefinancialnumberscomeexclusivelyfromhospitalbasedstudies–whatwouldhappenifweincludedoutpa.entandhomecareseRngs?Andthesenumbersdon’tincludethe“non-preventable”events(likeallergicreac.ons)thatmightdoublethefigures.Theimpactofmedica.onerrorsonnursesisalsoanimportantfactor.SchelbredandNord(2007)studiedtennurseswhohadcommiGedmedica.onerrorsthatresultedin,orhadthepoten.altoresultin,significantharmtothepa.ent.Theyfoundthatmakingamedica.onerrorwasdevasta.ngtoboththepersonalandprofessionallifeofnurses,whowereexposedtocri.cismandreproachfromtheirsupervisors.Somenurseswereunabletocon.nuetheirprofessionorfindanotherjobbecausetheyfeltembarrassedandashamed.Thosenurseswhocon.nuedtoprac.cehadafearofmakingnewmistakes,adecreasedconfidenceintheirownabili.esandfeltincompetentbecauseofsupervisionbytheircolleagues.Theprac..onerbecomesavic.mwhenprovidingcareina“shameandblame”environmentthathasliGletoleranceforpa.entcarefailuresaGributabletohumanerror.Further,theprac..oner—ifaphysician—hasbeenacculturatedinaneduca.onandtrainingenvironmentthatviewsthephysicianasbeingatthetopofthecarehierarchyandthereforetheaccountableparty.Therearemanyprogramsouttherefor“secondvic.ms”andthetermhasbeguntochangetotheconceptof“caringforthecaregiver”.TheCommunica.onandOp.malResolu.on(CANDOR)programputoutbyAHRQprovidesaprocessforrespondinginajustwaywhenunexpectedeventscausepa.entharm.TheforYOUteamattheUniversityofMissouriHealthSystemsupportsdistressedemployees,providing“emo.onalfirstaid”.Theseprogramsarerunbytheorganiza.oninwhichtheerroroccurred.Therearefewprogramsoravenuesofsupportforemployeeswhonolongerworkattheins.tu.onwheretheerroroccurred.ThePropublicasiteisoneplacetolookforhelp,aswellasafacebooksupportgroupcalled“showmeyourstethoscope”–butthereisnoformalsystemforsuppor.ngthosewhohavebeeninvolvedinanerror.Helpishardtofind.

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AtthePa.entSafetyMovementPa.entSafety,Science&TechnologySummit,SenatorBarbaraBoxer(D-Calif.),sharedalistoftheninemostcommonmedicalerrorsintheUnitedStates.AddressingaGendees,sheexplainedthatwhenPa.entSafetyMovementFounderJoeKianimetwithherabouttheprevalenceofmedicalerrors,shewassurprisedtolearnhowcommontheywere.Herofficebegantoresearchtheissueandwaseventuallygivenalistofthetopninemedicalerrors,byoccurrencebyfederalagenciesthattracktheissue(Dunn,2014).Thisissurprisinglydifficultinforma.ontofind:IsearchedtheCentersforDiseaseControlandPreven.on(CDC),AgencyforHealthcareResearch&Quality(AHRQ),Ins.tuteofMedicine(IOM;whichisnowtheHealthandMedicineDivisionoftheNa.onalAcademiesofScience,EngineeringandMedicine),andtheNa.onalPa.entSafetyFounda.on(NPSF),andcouldnotfindalistofthemostcommonmedicalerrors.However,nomaGerthesource,medica.onerrorisatthetop.Prescrip.onerrorsarelistedinastudyfromtheNPSFasthetypeoferrorinambulatory(outpa.ent)caremostlikelytocauseharm.I’mfocusingthismoduleonmedica.onerrorbecauseitisatthetopofthislist,andbecausenursesspendanaverageof40%oftheir.megivingmedica.ons,withnosecondcheckstopreventerrors,andbecauseIamdoingresearchonmedica.onerror–Iamobsessedwithit–IknowwecandobeGer.

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NomaGerwhatsiteyougoto:NPSF,Ins.tuteforSafeMedica.onPrac.ces(ISMP)–thisisthedefini.on.Itisawidedefini.on–itcanincludeanythingfromtakingtoomanyibuprofen,withnoobservablenega.veeffects,toreceivingthewrongchemotherapydose,resul.ngindeath.AHRQ:Amedica-onerrorreferstoanerror(ofcommissionoromission)atanystepalongthepathwaythatbeginswhenaclinicianprescribesamedica.onandendswhenthepa.entactuallyreceivesthemedica.on.Remember–ourfocushereispreventableadversedrugevents.Thesearen’tallergicreac.ons,butresultfromamedica.onerrorthatreachesthepa.entandcausesanydegreeofharm.Itisgenerallyes.matedthatabouthalfofADEsarepreventable.Wehavealotofworktodo!

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Justtofurtherdefinemedica.onerror-TheNa.onalCoordina.ngCouncilforMedica.onErrorRepor.ngandPreven.onhasanIndextorankerror.TheoneswecareaboutmostarecategoryE-I.Thisindexiswidelyusedtoclassifyerrors,andisarequiredcomponentforanyreportouttotheJointCommissionofasen.nelormajorsafetyevent.Usingthiskindoftaxonomytoclassifyerrorassistsinaggrega.onofdata.

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Let’stakealookatthenursingrole.Simplyput,itistoadministermedica.onasprescribedwhilepreven.ngerrorandpa.entharm.Wearethelastlineofdefense–physiciansandadvancedcareprac..onersprescribemedica.ons,pharmacistsfilltheprescrip.on,andonenfindandpreventerrorsfromreachingpa.ents,andthenursegivesthemedica.on(again,findingandpreven.ngerrorfromreachingthepa.ent).Nursespreventupto70%ofprescribinganddispensingerrorsbeforetheyreachthepa.ent(Bates,2007).However,nursesmaycommitbetween26%and38%ofmedica.onerrors(Bates,2007).Ina2010survey:78%nursesadmiGedtomakingaMedica.onError(Jones,2010).Weknowthereismuchmoretothenursingrolethansimplyadministeringmedica.ons.Theen.renursingprocessisinvolved:assessment,diagnosis,planning,interven.onandevalua.on–andthiscyclerepeatsitselfmul.ple.mesdailyformul.plepa.entsandmul.plemedica.ons.Mostcommonmedica.onadministra.onerrorsaredoseomissionandwrong.me.

Recallthatmosterrorscometolightbecauseanurserecognizestheerrorandchoosestoreportit…orhas.metoreportit.Whatifthenursedoesn’tthinkit’sanerror?Whatifshedoesn’tevenknowshemadetheerror?Asyoucanimagine,themostcommonerrorsareomission–thedosethatisn’tgiven,and

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Whatgoesinto“administeringmedica.onasprescribed”?Inaddi.ontobeingawareoffederal,state,andins.tu.onalregula.ons,nursesalsoneedtoknowthenurseprac.ceactandtheirscopeofprac.ce.Hereisalistofthingsnursesneedtoknowabouteachmedica.ontheyaregiving:1.  Generic-givenbytheoriginalmanufacturerwhichbecomesthedrugsofficialname,vs.

Trade-nameunderwhichthedrugismarketed.2.  Lookalike/soundalikedrugs-listproducedbytheIns.tuteforSafeMedica.onPrac.ces

andtheJointCommission.3.  Classifica.on-indicatestheeffectofthedrugonthebody/siteofac.on.4.  Medica.onForm-theformthemedica.oncomesinsuchastablet,elixir,powder

inhala.on,oneneffectsabsorp.onandmetabolism5.  Pharmacokine.csdescribeshowamedica.onentersthebody,reachandac.vestatefor

ac.on,metabolized,andexcretedwhentheireffectshavebeenobtained6.  Therapeu.cEffect-theexpected,desiredeffectoftakingamedica.onvs.Sideeffect-

expected,unavoidableeffects,attherapeu.cdoses.Adverseeffect-undesirable/unpredictablesideeffects,onensevere,Toxiceffect-maybearesultofprolongedexposuretodrugorexcessivelyhighdosage,accumula.onintheblood,maybelethalintheirresults

7.  Idiosyncra.creac.ons-unpredictableoverorunderreac.onofapa.enttoamedica.oni.e.Benadrylmakingachildclimbthewallswhenitshouldreallymakethemsleepy.

8.  Allergicreac.on-animmuneresponseiselicited,releaseofan.bodiesbythebody-Anaphylac.c-life-threatening,reac.onconstric.onofbronchiolarmuscles,edemaofthepharynx/larynx,severewheezing,ShOB

9.  Timing:onset,peak,trough,dura.on,half-life,10.  Route:Parenteral,SQ,IM,IV,Non-parenteral,Oral,Sublingual-underthetongue,Buccal-

mucousmembranesofthecheek,Topical,Inhala.on,Intraocular11. Measurement:Metric-mL,mg,g,L,Household-drop,cup,tbsp.,tsp.,oz.GOTIT?

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Howdidwegethere?Sinceabout1893,wehavebeentaughtthe5rightsasthenumberoneprocessforsafemedica.onadministra.on.ThefiverightswerefirstseeninTheNursingSister:AManualforCandidatesandNovicesofHospitalCommuni-es,1893(Wall,2001).Nursingsisterstaughtfiverightstopreventerror:rightpa.ent,medica.on,dosage,routeand.me(Eisenhauer,Hurley,&Dolan,2007).Sincethen,therehavebeenanincreasingnumberofrights:clienteduca.on,documenta.on,clientrighttorefuse,assessment,andevalua.onoftheclientanerthemedica.onisadministered(PoGeretal.,2013).Despitealltheserecommenda.ons,therearefewformalizedsystemsinpa.entcareseRngsforwhichrightstouseandhowtousethem.Thenumberofrightsincreases,buterrorratesdonotchange.Ihavetriedtofindresearchtosupportuseofthe5rights–thereisn’tmuchoutthere–norandomizedclinicaltrialsshowingthatusingthe5(or6,7,8,9)rightsimprovespa.entsafetywhencomparedtosomeothermethodofsafemedica.onadministra.on.

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Hereisasampleclinicalevalua.ontool.Recallhowyouwereevaluatedinnursingschool?Doyoudoallthesethingsnowthatyouareanurse?Doyoudoallofthemwhen“nooneiswatching”Doyouhaveopinionsaboutwhatworksandwhatdoesn’t?Isitevenpossibletodoallofthesethingsforeverymedica.onandeverypa.ent?

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Asanurseeducator,Ihavewatchedmanynursingstudentspainstakinglyfollowtheserules–tothepointofdistrac.on.Theyaresocaughtupinfollowingtherulesexactly,thattheyforgetwhattheyareactuallydoing.Whenandiftheyeventuallybecomeanurse,theyfindoutwhatweallfindout–thatthesethings–the5rights,thethreechecks–arenotdoneevery.me,thattheybecomerote,thatwefindwork-arounds,thatwegetcomplacent,anderrorsoccur.Thebigques.onis–howmanyofthoseerrorswerebecausewedidn’tfollowthe5rightsand3checks,andhowmanywereduetosystemerrors?Arethereperhapsbiggerproblems,thatiffixedcouldpreventanurseevenhavingthechancetomakeamistake?

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AsIstatedpreviously,ina2010survey78%ofnursesindicatedtheyhadmadeamedica.onerror(Jones&Treiber,2010).Reportshavesuggestedthatnursesareresponsiblefor26to38percentofmedica.onerrors(Bates,2007;Leapeetal.,2002).Hereiswhatgetsme:thelikelihoodofanursecomple.ngaprofessionalcareerwithoutmakingamedica.onerrorisverylow(Anderson&Webster,2001).Mosterrorsaremadebyhardworking,highlytrainedhealthcareproviders.Wecallthis“Thesharpendofcare.Thesharpendishowpa.entsafetyexpertsrefertodirectcare-theDr.performingsurgery,thenurseadministeringmedica.ons,thepharmacistmixingan.bio.cs.Themodernpa.entsafetymovementfocusesonsystemsthinking(called“thebluntend”moreonthatlater)–understandingthattoerrishumanandthatdespiteourbestefforts,wewillcon.nuetomakemistakes.“Safetydependsoncrea.ngsystemsthatan.cipateerrorsandeitherpreventorcatchthembeforetheycancauseharm”(Wachter2012).Thisapproachhasbeenusedinnuclearpower,avia.on,chemicalengineering–allhighriskindustries–withgreateffect.TheIOMdeclaredthat“thebiggestchallengetomovingtowardasaferhealthsystemischangingtheculturefromoneofblamingindividualsforerrorstooneinwhicherrorsaretreatednotaspersonalfailures,butasopportuni.estoimprovethesystemandpreventharm”

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Let’stalkaboutsystemstheory.Bri.shpyschologistJamesReasonwrote“HumanError”backin1990,proposingtheswisscheesemodeloforganiza.onalaccidents.Themodelcomesfromaccidentinves.ga.ons.The“sharpend”isthepersoninthecontrolbooth.Themodelacknowledgesthatasingleerrorisrarelyenoughtocauseharm–harmoccurswhenmul.pleerrorspenetratemul.plelayersofincompleteprotec.onleadingtoharm.Alltheunderlyingcondi.onsthatmadetheerrorpossible(maybeeveninevitable)arethe“bluntend”alsoknownas“latenterrors”.Reasonencouragesustofocuslessonthepointlessgoalofbeingperfect,andmoreonblockingtheholesinthecheese.Analysisneedstofocusonrootcausesandnotjustthesmokinggun.

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Let’sdiscussacasefromWachter(2012)originallypublishedintheAnnalsofInternalMedicinein2002(Chassin).Inalargehospital,apa.entnamed“JoanMorris”iswai.ngtobedischargedanersuccessfulneurosurgicalprocedure.Onadifferentunit,“JaneMorrison”isscheduledforthefinalelectrophysiologystudy(EPS)oftheday.Inthisprocedure,acatheteristhreadedintotheheart,star.ngandstoppingtheheartrepeatedlytofindthecauseoffatalrhythmdisturbance.TheEPSlabcallstheunittosenddown“Morrison”buttheclerkhears“Morris”andtellsthenurseforJoanMorristhattheEPlabisreadyforherpa.ent.Thenursethinks“that’sfunny,mypa.entwashereforaneurosurgicalprocedure.”Sheassumesoneofthedoctorsorderedthetestwithouttellingher,soshesendsdownthepa.ent.Laterthatmorning,theneurosurgicalresidententersJoanMorris’sroomtodischargethepa.entandisshockedtofindthatsheisintheEPSlaboratory.HerunsdowntotheEPSlabandistoldthattheyareinthemiddleofadifficultprocedureandcan’tlistentohisconcerns.TheresidentassumestheaGendingorderedtheprocedurewithouttellinghimandhereturnstowork.TheprocedureisfinallyabortedwhentheneurosurgeryaGendingcomestodischargethepa.entandfindssheisintheEPSlaboratory.Theprocedurecausednolas.ngharmandthepa.entremarked“I’mgladmyheartcheckedoutOK”Onascrappieceofpaper(oronthediscussionboardforthispresenta.on)jotdownwhyyouthinkthiserroroccurred.Onemainreasonmayjustpopintoyourhead,youmaythinkofmany.

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Sowhatcausedthiserror?I’minterestedinwhatyouwrote.Tomethemostobviouserrorisnotusing2pa.entiden.fiers.ThisisknownasaRedRuleviola.on.RedRulesareassociatedwithactsthathavethehighestlevelofrisktopa.entoremployeesafetyifnotperformedexactlyeachandevery.me.ThemostcommonlydiscussedRedRulesare:1)Timeoutsshallbeperformedpriortoallprocedures;2)Twoformsofiden.fica.onshallbeusedtoiden.fypa.entsbeforetakingac.onwithapa.entorpa.entinforma.on;and3)Allspecimensshallbelabeledatthepa.ent’sbedside.Soaredrulewasviolatedinthepa.entroom,andIsupposewecanassumethata.meoutwasnotperformedpriortotheprocedureeither.Andyoucanimmediatelythinkofsolu.onstothismistake,including–theyshouldhavebeenmorecareful.Iknowmanyofyouarethinking“Iftheyhadjustfollowedtherules…”Andmaybeyouareblamingthenursefornotspeakingupabouthermisgivings?Mistakesweremade.Areweallowedtomakemistakes?Ifyouanswer“no”,thatisalotofpressuretoputonfalliblehumanbeings.

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Let’sexploremistakesand“slips”morefully.Errorsmadebyindividualsareatthesharpend–theyareac.veerrorsinvolvingslipsandmistakes.Aslipinvolvesanautoma.cprocess;somethingwehavedonesomany.mes,wedon’thavetothinkaboutit-likeaveterannursehanginganIVbag,ordrivingacar.Amistakeinvolvesaconsciousprocess--somethingnew–somethingwedohavetothinkabout–changingatracheostomyforme!,drivingas.ckshinvs.anautoma.c.“Slips”occurwhenweputtasksonautopilot(forgeRngtoopentheclamponthesecondaryIVbag;drivingtoworkonadayoff…yourcarseemstoknowtheway!Thatisyourunconscious)“Mistakes”occurduetoincorrectchoices–lackofknowledge,experience,informa.on,inabilitytointerpretinforma.oncorrectly.Choosingtochangethattrachwithoutreviewingtheprocedure.Consciousac.onsaremorepronetoerror,butaslipmaypresentagreaterthreattopa.entsafety.Wearemostlikelytomakeanerrorwhendoingsomethingwehavedoneathousand.mescorrectly(Wachter,2012).Healthcareworkissocomplex–likepilotsandnuclearpowerplantworkers,weareexpectedtodomanytasksunderpressurewithahighdegreeofaccuracy.Unlikethoseworkers,doctorsandnursescombinethreedifferenttypesoftasks–lotsofcomplex/consciousac.ons,customerservice,andinnumerableunconsciousac.ons.Sowhatdowedowhenanursemakesasliporamistake?Reasonstates,“errorsarelargelyuninten.onal.Itisverydifficultformanagementtocontrolwhatpeopledidnotintendtodointhefirstplace”.Ourfirstimpulseistoblameothers–

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Iamsurebynowyouareaskingyourself“sowhataboutthebadnurses?”AndIagree–wehavetotakeintoaccountthefewbadapplesinthebunch–thosefolkswhomakeegregiouserrors.Therearetoolsfortellingthedifferencebetweensimplehumanerror(calledaslipormistake)and“atrisk”orrecklessbehavior.ThisisthetooltheNorthCarolinaBoardofNursingusestoevaluate“complaints”.Thetoolwasdevelopedfromthewri.ngsofDavidMarxonJustCulture.Howcanweapplythisevalua.ontooltotheac.onsofthenurseinthe“wrongpa.ent”story?Shehadnopriorinfrac.ons,shehadbeenanursefor5years,andwhenconfrontedwiththemistakeshesaid“Ohno!Ican’tbelieveIdidthat!Ishouldhavedoublechecked”Hererrorisclearlyhumanerror.WhataboutthetechnicianintheEPSlaboratory?Hehadpriorcounselingforapreviousredruleviola.on,andwhenconfrontedwiththeerrorstated“Theyshouldn’thavesentmethewrongpa.ent”.Thedenialofresponsibilityisofmostconcerntome.Wherewouldhefallonthisevalua.onform?Let’sstepoutsideofhealthcareforaminuteandthinkofitthisway.Thespeedlimitonaroadis65.Howfastdoyougo?Let’ssay70.Everybodyiszoomingpastyou.You'reintheslowlane,somostpeoplearegoing75or80.Sonowyou'regoing80,andthensomeguywhipspastyou;hemustbegoing100.Thelawsaystogo65;weallknowit.ManyofushavegoGen.cketsands.llchoosenottoobeythelaw,to

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Mostofushavemadeerrorsthatfallinthegreen;Icertainlyhave.Ihaveevenmadeerrorsfallingintheyellow.Ihaveusedthistoolrepeatedlywithnursingstudentstoshowthemthedifferencebetweenhumanerror,atriskbehaviorandrecklessbehavior.IhaveevenhadadiscussionwiththeBoardofNursingaboutapa.entcomplaintconcerninganursingac.onIperformed.IwasrelievedwhenIfoundoutIwasn’t“inthered”buttheimpactofthatexperienceonmyprac.ceandmypsychehasbeenintense.It’smyoriginstoryreally–howIbecameobsessedwithmedica.onsafetyThisisjustoneofmanytoolsforiden.fying“blameworthy”behavior–forsor.ngoutwhotodisciplineandwhotocoach.Othertoolsincludeaprofessionalismpyramid,HicksonPrichert,WebbandGabbe,2007,AcademicMedicine,andthereisoneintheWachterbookaswell;thePa.entAdvocacyRepor.ngSystem:PARS®Process;Montefiore’sPa.entSafetyProgram;JasonAdelman,MD,MS,Pa.entSafetyOfficer,2011.

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GeRngbacktoJoanMorrisandthecaseofthewrongpa.ent,animportantlayerofswisscheesewaslenout–oneatthebluntend(recallthesearelatenterrors)thatofSafetycultureissues.Oneofthese“bluntendissues”istheconceptof“steephierarchy”.Hierarchiesarepresentinallorganiza.ons,howeverinhealthcaretheyarepar.cularlyentrenched–thinkofthetradi.onalrela.onshipbetweenDr.andNurse.forexample,thenursedidn’tfeelempoweredtoconfirmthetestforherpa.ent,andthetechnicianintheEPSlabdidn’tlistentotheresident.Theseareindica.veoflarger,safetycultureissues.AnotherculturalissueisoneofLowexpecta.ons–thisconceptisbestdefinedintheaRtude:ifyou’renotsureitisWRONG,assumeitisRIGHT.Produc.onpressuresareanaddi.onalsystemissue.Theyareeasilyunderstoodwhenlookingatavia.on–companiesneedtomakemoneyandanairlinedoesn’tmakemoneyifplanesaregrounded,butregardless,thefederalavia.onadministra.onenforcesahardandfastrulethatcloudcoverbelow3000ngroundsallplanes(causingmuchlossofmoneyinSanFrancisco)Thechoiceofsafetyoverproduc.onhasbeenmade,butinthehospitalwhereJoanMorriswasapa.ent,theculturewasoneof“hurryhurryhurry”numbershavetobemet.Interes.ngdifferencesbetweenhospitalsandavia.on:Ifahospitalisoverloadedwithpa.ents,canitclosethedoorstotheER?Healthcareisnotavia.on.However,iftheseissuesarenotaddressed,thenfuture,similarerrorislikelytooccuragain.

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Thishandychartshowssomeofthelayersofcheese.ItisaconceptualmodelbasedonReasonandVincent’swork(Vincent,1998).Thismodelhighlightssafetycultureasoneofthelatentcondi.onscontribu.ngtoerror.IfthehospitalwhereJoanMorriswasstayinghadasafetyculture–thenursemighthavefeltcomfortableques.oningtheDr.,theEPStechwouldhavelistenedtotheresident–hewouldhavefelthehadthe.metostoptheprocedure,knowingmanagementwouldbackhimupwiththemoGo“beGersafethansorry”.Then,evenifthewrongpa.entwassentdown,aswillcon.nuetohappen,despitealltheredrulesweputinplace,theerrorwouldhaves.llbeenprevented.

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Thisisanerrorfromanar.clebyBates,publishedin2002.Ms.Grantwasa68-year-oldwomanwhohadcardiacbypass.Shewasmuchimprovedaneradifficultpostopera.vecourse.OnthemorningofherplannedtransferoutoftheICU,shehadagrandmalseizure.Shehadnohistoryofseizureandwasnotonanyan.-seizuremedica.ons.BloodwasdrawnandshewastakenforaCTtoruleoutstrokeorcerebralhemorrhage.Whileintransit,thelabpagedthephysiciantoreportherserumglucosewasundetectable.Despitemul.pleinfusionsofglucose,sheneverawoke.Intheinves.ga.onthatfollowed,itwasfoundherIVhadbeenflushedwithavialofinsulin,vs.theprescribedheparin.Thevialswereofsimilarsizeandshape.Thenursehadaccidentallyadministeredafataldoseofinsulin.Again,onascrapofpaperoronthediscussionboardforthistopic,writedownwhyyouthinkthiserroroccurred?

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Whenyouasknurses,theansweris,it’smostlyallourfault.Nurseshaveiden.fiedthatcarelesslyfailingtofollowthefiverightsandnursingincompetencearemajorcausesformakinganerror(Jones&Treiber,2010).Nursesappeartobelievethattheyshouldbecapableofadministeringmedica.onswithouterrors,regardlessoftheexternalcircumstances.Cohenetal.,polled779nursesin2003,and79%agreedthatmedica.onerrorsoccurwhenanursecarelesslyneglectstofollowthe5rights.58%believedthatthecommissionofamedica.onerrorwasindica.veofnursingincompetence.Inthesamestudy,58%viewedcommissionofamedica.onerrorasanindicatorofincompetence.In2008thesamepollwasconductedandthosenumbershaveonlyincreased.Thisstudyhighlightsthatnega.veopinionsandindividualblamecon.nuetobeassociatedwitherrormaking(Cohen&Shastay,2008).Nurseshavealsoreporteddistrac.ons,interrup.ons,inadequatestaffing,illegiblewriGenorders,incorrectdosagecalcula.ons,similardrugnamesandpackaging,andfailuretofollowpoliciesandproceduresasreasonsformakingmedica.onerrors.Othercontribu.ngfactorsareworkplacestress,inadequatetrainingandfragmentedinforma.on(Pape,Guerra,&Muzquiz,2005;Schulmeisteretal.,2010).Inaddi.on,ArmitageandKnapmanreportednewnurseswerehesitanttostatethatamedica.ondrawnupbyanexperiencednursewasincorrect,demonstra.ngdeferencetoauthorityasacauseofmedica.onerror(2003).There’sthathierarchyissueagain.

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It’sactuallydifficulttogetatwhymistakesoccur–thinkabouthowerrorsarereported:voluntaryself-report.Thepersonrepor.ngstateswhytheythinktheerroroccurred,butwithouttraininginrootcauses,youcanseeitiseasyfornursestosimplyblamethemselves.Wedon’tinves.gateeveryerrorreport–thatwouldtakeforever,sowedon’treallyknowhowgoodweareatself-report.Thischartisonewaytolookatcausesoferror–allsen.neleventsareinves.gatedandreportedtotheJointCommission.Communica.onwasthemostcommonreasonforerrorresul.nginharm,followedbyorienta.onandtrainingissues,andpa.entassessment.No.cethatcompetencyisinthere–becausewearenotsayingNOONEistoblamewhenerrorsoccur.Iammakingthecasethatusually,itisnotincompetencealoneandthatotherfactorscomeintoplay.

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ThisframeworkwasputtogetherbyVincent–itshowsthemyriadcontributoryfactorsthatcanleadtoanerror.Itisofinterestthatnursesiden.fyreasonsforerroronlyatthesharperendofthes.ck–latentfailuressuchasregulatorycontextorpoorsafetyculturearenotiden.fiedbynursesasreasonsformedica.onerror.AlsoofinterestisthelackofaGen.onwepaytothecomplexityofthepa.ent.Let’sgobacktothenursewhoaccidentallyflushedthepa.entlinewithinsulininsteadofheparin.Atthesharpendofthes.ckisapossiblyinexperienced,orincompetentnursewhodidn’tfollowthe5rights,butkeeplookingtowardsthebluntendandweseesimilarpackaging,distrac.on,inadequatestaffinganddeferencetoauthorityaspartofalargersafetycultureissuemayalsohaveplayedarole.Perhapsthenursewhogavethemedica.onknewthatthemedica.onhadbeenpulledbyanexperiencednurse,soshedidn’tbothertocheckit;maybeshewasinahurry,maybetheligh.ngintheroomwaspoor.Maybeaphysicianwasintheroomtappinghisfootwithimpa.encewhilethenurseflushedtheline.Onlyinves.ga.onwillshowalloftherootcauses.

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Andfinallywehavecometosolu.ons.Howdowefixthismess?ThislistisfromthatFrameworkIshowedyouinanearlierslide,proposedbyVincent,showingcontributoryfactorstoerror,organizedfromthebluntorlatentendatthetoptothesharporac.veendattheboGom.Iamgoingtodiscusssolu.onsalongthespectrumfromlatent,systembasedsolu.onstoac.ve,individualsolu.ons.Eachstepisonachecklistonmywebsitethatyoucanusetoanalyzeyourprac.ce;orifyouareanewnurse,youcanaskques.onsaboutthechecklistwhentakingajob–youmightdecidenottoworksomewherethathasapoorsafetyculturescore,andinsteadchoosetheins.tu.onthathasarobustsafetyculture.Ins.tu.onalsolu.onswillfocusonregulatorybodies,accredi.ngagenciesandlegalissues–thinkna.onal–think–whatdoIhavetodotostayopen?Theorganiza.onallevelfocusesonsolu.onsatthelevelofmanagementandleadership––whatdoIhavetodotokeepcustomerscomingback,tokeepmystaffhappy,tomakemoney?Isthereanythingintheenvironmentthatcanberedesignedtosupportsafety?TechnologyisalsodiscussedwithCPOEisanexample.Thediscussionofpoliciesasksdoweneedmorethan5rights?Andwhataboutteam-howdoesthewaytheteamfunc.onsaffectpa.entsafety?Solu.onsforstaffmemberstellyouwhattheindividualcando,tominimizethelikelihoodyouwillmakeamistake.Asastaffnurse,thismaybeyourfavoritepartofthelist.Thefinalfocusisonthepa.ent-whatcanIknowaboutthepa.ent,andwhatcanthepa.entandfamilydotominimizeharmfromerror?Sharetheselistswithpa.ents,friendsandfamilymembers–wecanallaskbeGerques.onsandexpectmorefromourhealthcareproviders.Whatisexci.ngaboutlookingatalltheselayers,isthatisonlytakesONElayertopreventanerror–takealookattheSwisscheese–it’sagreatexampleofhowinterven.onscanpreventerror.Iencourageyoutoaddtotheselists–emailmeorcommunicateonthediscussionboard–

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Ins.tu.onaltoolsareblunttools–theyhavelimitedabilitytotakeintoaccountlocalcircumstancesorins.tu.onalculture–examplesinclude“signyoursite”andaboli.onofhighriskabbrevia.ons–thesesolu.onshavethesameapplica.onin80or800bedhospitals.Regulatorybodiesarestategovernments(wehavefewfederalregula.ons).TheUShasnosingleen.tythatmandatesandregulatespa.entsafety.Medicareisafederalinsurancepolicysotospeak,andtheyhaveagreatdealofcontroloversafetypolicies.Forexample,therecentins.tu.onofMedicare’snopayforerrorslist–Valuebasedpurchasingpenalizeshospitalswithhighreadmissionrates-thiswillhopefullyhaveanimpactontheerrorrateinyearstocome.Stateregula.onsvary:somehavenursestaffingra.o,somedon’t–15statesregulatenurse-to-pa.entra.os,26requirerepor.ngofcertaintypesoferrors,7havepassedlawsmanda.ngerrordisclosure,10requirepa.entsadmiGedtohospitalsbescreenedforMRSA,PA&VAhaveaddedrequirementsforacertainnumberofhoursofpa.entsafety-specificcontentforlicenserenewal.Therearelinksonmysitetostatespecificregula.ons.Asanexamples,in2003,theNorthCarolinalegislaturepassedLaw2003-393,requiringeverynursinghome,beginningin2004,toestablishaMedica.onManagementAdvisoryCommiGeetoprovideacomprehensiveapproachtomedica.onerrors.Thebillwascodifiedintolaw,amending

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Accredita.onisanimportantsafetysolu.on.ThemostimportantaccreditoristheJointCommission–beganin1951.Un.lmid2000theJCannouncedvisits,butin2006visitsbecameunannounced.IfyoupassaJCinspec.on,youarealsoassumedtobeincompliancewithCMScondi.onsofpar.cipa.on-failureputsyouatriskforlosingMedicarepayments,thoughunaccreditedfacili.escans.llbillforMedicareandMedicaid.Mostambulatorysites(likesurgerycenters)andphysiciansofficesareunaccreditedoraccreditedbytheAmericanAssocia.onforAccredita.onofAmbulatorySurgeryFacili.es(AAAASF).Onlyabout1000nursinghomesintheUSareaccreditedbytheJointCommission.JointCommissionstandardssupportpa.entsafetyinmanyways.Theyhavemandatedtheuseofrootcauseanalysisforallsen.nelevents,in2006,inconjunc.onwiththeNPSG:theyimplementedastandardizedapproachtohandoffcommunica.onsincludinganopportunitytoaskandrespondtoques.ons.Othermandateshaveincluded:banninghighriskabbrevia.ons,useoftall-manleGeringforlookalike/soundalikedrugs;Zeros:Leaddon’ttrail.Anothersafetysolu.onistherecommendedleveloflicensureforentryintoprac.ce.Licensurestandardsaremaintainedatthestatelevel.Boardsofnursingandmedicinekeeptrackofsafenursingandmedicalprac.ceandprovidepubliclistsofthosewhohavebeendisciplinedorlosttheirlicense.Thoughresearchsupportsthathigherlevelsofeduca.oninthenursingworkforceresultinimprovedpa.entoutcomes,

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Anotherimportantsafetysolu.onistobeamemberoforobtaininforma.onfromprofessionalsocie.esandnon-profitsliketheNa.onalQualityForum.NQFisanonprofit,andoneofthemostimportantpa.entsafetyorganiza.ons.Theypublishedalistofneverevereventsin2002,andthelisthasgrownto29itemsandisnowcalled“Seriousreportableevents”.ThislististhebasisforMedicare’snopayforerrorsini.a.ve.TheNQFalsoendorsesalistofsafeprac.cescontaining34items.TheLeapfroggroupwasformedin2000tocatalyzepa.entsafetyac.vi.es,andin2001mandatedComputerizedPhysicianOrderEntry(CPOE),favoringhighvolumeproviders,andhavingfull-.meintensivistsforcri.calcare.TheIns.tuteforHealthcareImprovement(IHI–whichjustjoinedwiththeNPSF)campaigntosave100,000lives(2005)promoted6safetyorientedprac.cesinAmericanhospitals.In2006theyadded“prevent5millioncasesofharm”byadding6addi.onalprac.ces.TheAHRQpromoteseduca.on,disseminatesbestprac.ce,commissionsevidencereviews,convenesstakeholders;theyareasafetyleader.TheCentersforMedicareandMedicaidServices(CMS)in2011createdapartnershipforpa.entscampaign,drawingstrategiesfromIHIcampaigns.Legalsystemsafetysolu.onsarecontroversial.Manyhaveaskedifpa.entsafetyhasbeenimprovedbythelegalsystem?Malprac.celawsuitshavebecomecommonplaceandhavedriveninsuranceratesforhealthcareprovidersthroughtheroof.LegalissuesforcedAnesthesiologiststomonitorpt.o2levelscon.nuously–theydidn’tdothatbefore,andhasresultedinmuchbeGerdocumenta.on.Tortreformreferstoproposedchangesintheciviljus.cesystemthataimtoreducetheabilityofvic.mstobringtortli.ga.onortoreducedamagestheycanreceive.Itiscontroversial,butproponentssuggest,basedonevidenceinautoindustry,thatli.ga.ondoesn’timprovepa.entsafety.Intortlawyoumustlinkcompensa.onoftheinjuredtothefaultoftheinjurer,butthisdoesn’tworkwellinmedicinebecausesomanyerrorsinvolveslips–theyareuninten.onalandcannotbedeterredbythreatoflawsuit.Bothrecklessandcompletelycompetentphysicianswhomademistakesaretreatedthesamewayinacourtoflaw.Thosewhofailtoadheretoexpectedstandardsareonenunpunishedduetotortreform.AnexampleofoutcomesisthatDoctorsinCanadaare5xlesslikelytobesued,butmakesamenumberoferrors.Anotherlegalissueisthedifficultywithexpertwitnessesassumingthemindsetofthereasonableprac..oner,adifficulttaskintheblameandshameenvironmentofhealthcare.WeallseemtothinkwewouldhavedoneitbeGer.Itisgoodthatsafetyresearchislinkedtoregula.ons,malprac.celaw,mediascru.nyandpublicpressurebecausethesecanallleadtorapiddissemina.onofsafetyprac.ces:nurse-pa.entra.os,

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Intheabsenceofstateregula.ons,andaccredita.onrequirements–whatcananorganiza.ondotopromotesafety?Onesolu.onistomakeafinancialcaseforsafety–beyondtheideaofvaluebasedpurchasingisthatanorganiza.oncansaveconsiderablemoneybyfocusingonpreven.on–onenmakingacaseofactualdollaramountswillconvincehigherupstoinvestinsafetymeasures.IntheChecklistManifestobyAtuleGawande(2010),afinancialcasewasmadeforusingchecklistsbyoneofthefoundingfathersofthepa.entsafetymovement,Dr.PeterPronovost.Hespearheadedacampaigntou.lizeChecklistsforcentrallineinser.oninICUseRngs.In2006,theMichiganhospitalsysteminwhichthechecklistwasusedhaddecreasedcentrallineinfec.onsby66%,hadsavedanes.mated150milliondollars,andsaved1500lives.Manyofthehospitalsinthesystemhadreducedcentrallineinfec.onratestozero.Someareasthatareworththefundsareu.lizingtheexper.seofpharmacists.Pharmacysupporthasbeenshowninmul.plewaystoreducemedica.onerrorrates.Ifpossible,centralizedpharmacyserviceswhereyoubuyinbulkandbreakmedica.onsdownin-housecanbothimprovesafetyandsavemoney.Unitdosinghasbeenaroundsincethe60’sandisachievedbylargercompaniesthroughcentralizedpharmacyservices–itisassociatedwithfewermedica.onerrors,andreduc.onofrevenuelosses,butalsoinmorepharmacy.me/moneyspentonpharmacyprocessing.meandequipmentcosts.IoncedidanRCAforanadultdaycenter–theyhadtodoadailycountofmedica.onsandhaddifficul.eskeepingtrackofmedica.ons–why?TheyareallinboGles!The.meitwouldtakeeachdayforthenursetocountouthundredsofpillsfromeachpa.entmedica.onboGle–youcanimaginethatmistakesoccurred,andonenitjustwasn’tdone.Weneverdidacostbenefitanalysisofthepersonhoursspentbynursingvs.thecostofunitdosing.Ul.mately,safetycansaveyoumoney,beitintheformofli.ga.onexpenses,personhoursorreten.onofvalueemployeesthroughjobsa.sfac.on.Anotherimportantsafetysolu.onistoinvolvetheboardinpa.entsafetyefforts.TheIHIhasareallygoodsiteforac.vi.esforboardstofocusontopromotepa.entsafety.Eachboardmee.ngneedstoincludeatleastonestoryofanactualpa.entharmedorkilledwhilereceivinghealthcare.TheboardneedstoassistwithseRngaimsandhearingstoriesfromthetrenches,notjustnumbersandreports.Whenpa.entsafetyisvaluedfromthetopdown,itbecomesanorganiza.onalpriority.Benchmarkingisanothersafetysolu.on.Yourcompanyneedstocomparepa.entsafetyindicators,notjustwithitself,butwithlocal,stateandna.onalstandards.Goodsourcesforbenchmarksincludelocalqualitycollabora.veswhereseveralprac.cescollectsimilarperformancedataandcancompareamongthemselves.Communityclinicassocia.onsonenhostthistypeoflocaleffort,onenthroughmanagingmul.organiza.onQIprojectsonapar.cularcondi.onsuchasasthma,andmaybenchmarkacrossthepar.cipa.ngsitesaspartoftheirworkwiththeirmembers.Formoreinforma.ononspecifics,takealookatmychecklistandmywebsite.OthersourcesofdataforbenchmarkingcanberequireddatareportstoFederalagenciesandfunderssuchastheHealthResourcesandServicesAdministra.on’sUniformDataSystemandreportsrequiredfromFederallyQualifiedHealthCenters.Na.onalassocia.onsandtheNa.onalCommiGeeonQualityAssuranceareotherpoten.alresourcesforbenchmarking,aswellasStateandlocalhealthandpublichealthagencies.Healthinforma.ontechnologyvendorsarealsoemergingasasourceofbenchmarkswhentheyallowcomparisonacrossorganiza.onsusingtheirsystems.LargedatanetworkssuchasDARTNetandSAFTINetfundedbyAHRQmayalsobecomearesourceforbothlocalandna.onalbenchmarking.

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Thereneedstobeaclearfocusonpa.entsafetyfromleadershipincludingmodelinggoodbehaviors,maintainingconfiden.alrepor.ngsystemwithrobustfollowup,trainingmanagersinconflictresolu.on,teamworktraining,andstructuredcommunica.onprotocols.Takealookattheorganiza.onsmissionandvisionstatementstoseeiftheword“safety”ispresentandhowitispresented.Healthcareorganiza.ons,likeairlineshaveins.tutedCrewResourceManagement(CRM)todampenauthoritygradients.WithCRM,interdisciplinaryteamsactuallyprac.cecommunica.onwithscriptsthatincludehowtobreakdownhierarchicalbarriers.AHRQhasafreecurriculumforteambuildingcalledteamSTEPPS:StrategiesandToolstoEnhancePerformanceandPa.entSafety.ManagementcanseekoutanduseFailureModeEffectsAnalysis(FMEA);ausefultooforwork-arounds,whenfrontlineworkersfindawayaroundcommonsensesafetyfixesiftheygetinthewayoftheirperceivedabilitytodotheirjob.Humansarefallibleandonenoveres.matetheirabili.esandunderes.matetheirlimita.ons.AnexampleofhowFMEAcanhelp–ahospitalIworkedinprovidedhandsani.zeroutsideeveryroom–theonlyproblem?nurseshavetheirhandsfull,withnoplacetosetthingsdowntosani.ze!Butthatisasmalllossof.meandrevenuecomparedtoa4yearoldwithcomplicatedcardiacissueswhodiedduetoherECGleadsbeingpluggedintoanIVinfusionmachine,whichdeliveredafatalshock.Thecordsmatchedinsizeandshape–FMEAofthatsitua.onmighthavepreventedherdeathbyiden.fyingtheissuebeforeaproblemoccurred.RootCauseAnalysisshouldbeinplacealreadyfor

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Ahugesolu.onforanyorganiza.onfocusedonpa.entsafetyistoadoptacultureofsafety.Anorganizedpa.entsafetyprogramwithadedicatedpa.entsafetyofficerisanimportantstep.In2012,AHRQiden.fiedPa.entSafetyCultureFocusAreas(thisisaminichecklist):Communica.onopennessFeedbackandcommunica.onabouterrorFrequencyoferrorsHandoffsandtransi.onsManagementsupportforpa.entsafetyNonpuni.veresponsetoerrorsOrganiza.onallearning—con.nuousimprovementOverallpercep.onofpa.entsafetyStaffingSupervisor/managerexpecta.onsandac.onspromo.ngsafetyTeamworkacrossunitsTeamworkwithinunitsYoumayhaveheardthetermhighreliabilityorganiza.on(HRO)inrela.ontopa.entsafety.AHighreliabilityorganiza.onreferstoorganiza.onsorsystemsthatoperateinhazardouscondi.onsbuthavefewerthantheirfairshareofadverseevents.Commonlydiscussedexamplesincludeairtrafficcontrolsystems,nuclearpowerplants,andnavalaircrancarriers.Itisworthno.ngthat,inthepa.entsafetyliterature,HROsareconsideredtooperatewithnearlyfailure-freeperformancerecords,notsimplybeGerthanaverageones.TobeanHROrequiresadop.onofaSafetyculture–thiscanbemeasuredwithtwodifferenttoolsthatareopenaccessandcanbefoundontheNPSFandAHRQwebsites.Itisimportanttoorganizeyoursurveyprocessbecausetheresultsunitbyunititcanreallyvary.Anothersafetysolu.onisincidentrepor.ng(IR)systems,whicharebasedonavia.onrepor.ngsystemins.tutedin1974.Intheavia.onindustry,theirusecauseda10folddecreaseinfatali.es.Intheirsystemanear-missmustbereported–andyoudon’treallyneedtoreportcrashesbecausetheyareonthenews!Theamountofdatacomingfromhealthcareisatleast3ordersofmagnitudegreater,soweneedtoconsiderthatInsteadofrepor.ngallerrors,organiza.onscaneffec.velysamplecommoncategoriesindepthforshortperiodsof.me.ThepurposeofIRisnotdatacollec.on,butqualityimprovement.IRneedstobereportedtomanagers,andresultsneedtobecommunicatedwithallstaff,forexampleinMorbidityandMortalityConferences.Therehavebeensuccesseswithpublicsystems:MEDMARX,ISMPsystem.Barrierstorepor.ngneedtobeaddressedsuchasthe.meittakes,liability,embarrassmentandshame.Becauseweonlycaptureafrac.onofincidents(recallfromearlierslideshowfewerrorsarevoluntarilyreported),IRmustbecombinedwithretrospec.vechartreviews,directobserva.onand/oruseoftriggertools.Asignthatyourorganiza.onhasahealthysafetycultureisthatmanyreportsareofnear-misses,wherenoharmhasoccurred.Justcultureispartofsafetycultureaswell.Whenerrorsaremetwithafairandjustresponse,itstrengthensstaffconfidencetoraiseques.onsandconcerns.Thispushesthecycleofsafetyintherightdirec.onbyiden.fyingproblemsandfixingthembeforetheycauseharmtopa.ents.Inajustculturethereisaclearandtransparentpolicyonestablishingblameworthybehaviorsasdis.nguishedfromhumanerror.Yetanothertoolisstandardiza.on:Thereisthestoryofanursewhoworkedattwodifferenthospitals.Atonehospital,ayellowwristbandindicatedarestrictedextremity.Attheotherhospital,shehadapa.entwitharestrictedextremity,sosheputayellowwristbandonhim,butatthathospitalyellowindicatedDNR.Thepa.entcodedandtheteamalmostdidn'tresuscitatehim.Andnow,colorsarestandardized.

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Thisisfigure2frommypublica.on:Miller,K.,Haddad,L.,Phillips,K.(2016).Educa.onalStrategiesforReducing

Medica.onErrorsCommiGedByStudentNurses:ALiteratureReview.Interna-onalJournalofHealthSciencesEduca-on.3.

Iampresen.ngithereasasidenotetoillustratetheimportanceofintroducingtheseconceptswhennursesares.llinnursingschool.Thinkabouthowerrorsweretreatedwhenyouwereinnursingschool.Atmymostrecentjob,studentsreceivedapuni.vewriteupwheninvolvedinerror,theerrorswerenotcollectedoraggregatedorsharedwiththeotherstudents.StudentslivedinconstantfearofgeRng“kickedout”ofschoolformakingamistake.Thefollowingisfromachecklistavailableonmywebsiteforeduca.onalstrategiesforreducingerror:Educa.onalstrategies

CurriculumreformQualityandSafetyEduca.onforNursesPharmacology–dedicatedcourseInterdisciplinary-experienceswithpharmacyandmedicalstudents

Strategies:Contextualizeinstruc.on–simulatedpa.entsthatarefollowedthroughtheprogramRepe..onRiskfreeenvironments–simula.onwithnoconsequences

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Apolicyisaguidingprincipleusedtosetdirec.oninanorganiza.on.Aprocedureisaseriesofstepstobefollowedasaconsistentandrepe..veapproachtoaccomplishanendresult.Inastudyofmalprac.cecases,medica.onerrorswereassociatedwithlackofadministra.onprotocolsandineffec.venursesupervisionindelega.ngadministra.on(Hughes,2008).Policiesandproceduresneedtobeeasytoaccessandeasytounderstand.AsahomehealthnursewithspoGywifi,itwasonendifficulttoquicklyandeasilypullupapolicyorprocedureinthefield.Un.lcomputersonwheels,theseitemsonenlived(ands.lldoinmanyplaces)in3ringbinders,whichcandisappearandarenotoriouslydifficulttokeepupdated.Aspreviouslymen.oned,anothersafetysolu.onistoIncreasethenumberofrightsfrom5;thereiscontroversyoverhowmanyrightsareneeded,butwhatseemstomakethemostsenseisanins.tu.onalstandardizedusedofrights.ThereneedstobeaclearprocedureforIndependentdoublechecks-Doubleandeventriplechecksareused,butonlyworkiftheyaretrulyindependent–it’seasyforthesecondchecktobecomerote;andissubjecttoissueswithhierarchy–newnurseshavereportedfindingitdifficulttodisagreewithexperiencednurses.Istheprocedureforcaretransi.onsclearandisitfollowed?–transi.onsneedingmedica.onreconcilia.onarewherethegreatesterrorsoccurintransi.onofcare.30%ofpa.entshaveadiscrepancyatadmissionandattransferofcare,and14%atdischarge.AHRQhasafreetoolkitcalledMATCH:Medica.onsatTransi.onsandClinicalHandoffstosupportsafertransi.ons.ProjectRe-EngineeredDischarge(RED)hassaved$150/dischargebyins.tu.ngapre-programmedcomputeronwheelswithindividualpa.entinforma.on,combinedwithanswerstodiseasespecificandgeneralques.ons.Pa.entspreferred“Louise”tothe90

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Acommunica.onpolicywithproceduresforhowtocommunicateisvital.AhighlyrecommendedtoolisSBARwhichstandsforSitua.on,Background,Assessment,Recommenda.on.Physiciansaretrainedtospeakthiswaytooneanother,butmanynursess.lldon’thavethehangofit.Anotherareaoffocusforcommunica.onistheuseofCUSwords.ProvidersaretrainedtousethewordsConcerned,Uncomfortable,andSafetyissueinescala.ngorderofwordusagetoindicateeleva.nglevelsofconcern.Traininginvolvesteachingprovidersnottooverusethewords,sotheysendaclearsignalofconcern.Wecantalkaboutpolicyandprocedureallday,butittheyarenotenforced,aclimateoffrustra.onandlackofrespectcanbecreated.Theconceptofholdingpeopleaccountableinasafetycultureiscalled“JustCulture”:itisimportanttofindbalancebetweenmovingawayfrom“blameandshame”andestablishingandenforcingstandards.Forexample,70%ofphysiciansbelievetheyshouldreportimpairedorincompetentcolleagues,but33%statetheyfailedtoreportsomeonetheythoughtwasimpairedtotheauthori.es.Therearebadapples,andstrongevidencethattheyarenotdealtwitheffec.vely.5%ofphysiciansareinvolvedin54%ofpayoutsformalprac.ce.Only1/6hadbeendisciplined.WeneedbeGerwaystodetermineifdoctorsaremee.ngrelevantprofessionalstandards.Whatshouldbedoneaboutaphysicianwhochoosesnottodoa.meoutbeforesurgery?Thereneedtobepoliciesandproceduresfordealingwithdisrup.vebehaviors–In2008theJCcalledforazerotolerancepolicyfordisrup.vebehaviors.Interpersonalinterac.onscanimpededeliveryofcare.Anotherimportantpolicytohaveonboardiscaringforthecaregiver.Organiza.onsandindividualsneedtoeasilylocateinforma.ononhowbesttosupportthosewhohavebeeninvolvedinerror.Anexampleisthe“forYOU”teamdevelopedatUniversityofMissouri,ins.tutedin2007tosupportstressedemployees.Theyprovideemo.onalfirstaidby

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Theworkenvironmentinvolvesnotonlythephysicalsurroundings–thingslikeroomsize,ligh.ngandtypeofflooring,butalsostaffinglevel,mixofskills,andpaGernsinworkloadandshins.Staffing/produc.onpressureisabigissue–medicalerrorsincreasewithhigherra.osofpa.entstonurses.Inonestudy,foreveryaddi.onalpa.entaddedtoanurse’saverageworkload,mortalityrose7%andburnoutanddissa.sfac.onincreased23%and15%respec.vely.Whatisevenmoresurprisingisthereisnodatalinkingphysicianworkloadandpa.entsafety.Fromthetopdowninhospitals,paymentrewardsproduc.vityoversafety.Andthenthereistheculture–don’tcomplain!Physiciansaretaughttoworkun.ltheydrop,nursesbragaboutneverusingthebathroomortakingabreak.A2002IOMreport.tled,“KeepingPa.entsSafe:TransformingtheWorkEnvironmentofNurses”examinestherela.onshipbetweennursing’sworkenvironmentandpa.entsafety.Thereportdiscussesissueslikeshinlength,theeffectsofnightshinsandrota.ngshinassignmentsoncircadianrhythmsandworkperformance,andtheeffectoftemporarystaffonpa.entsafetyandthequalityofcare.Studieshaveshownthatpa.entsaremorelikelytodeveloppneumonia,cardiacarrest,urinarytractinfec.onsandupperGIbleeding,andexperiencelongerhospitalstaysinhospitalswithlowernursestaffinglevels.Specifically,theseproblemsoccurwhentherearefewRNscomparedtolicensedprac.calnursesornursesaides,orinsitua.onsinwhichRNsarenotabletospendadequate.meassessingandmonitoringpa.ents.Researchcon.nuestodemonstratetherela.onshipbetweenadequatestaffingandpa.entsafetyinallhospitaldisciplines.Workenvironmentalsospeakstotheneedforthemixofstaffing.Mul.plestudieshaveshowntheuseofclinicalpharmacists,outofallinterven.onsforreducingharmfromerror,isthemostpowerful.Inser.onofclinicalpharmacistsintoanICUresultedina3xreduc.oninADE,howevertheUShasashortageofpharmacists,andthecostishigh.Nursesdon’tonenknowhowmuchtheycanrelyonpharmacists.Asanoncologynursegivingchemo,Iwaswellaware,butittookmeawhiletorealizeasahomehealthnurse,thatthepharmacistsatthelocaldrugstorearealsoagreatresource.Actualphysicallayoutcanplayaroleinsafety.Theconceptofa“nointerrup.onzone”inwhichtapeisplacedaroundthemedcarthasgainedsupport.Thereisanaverageof1.2interrup.onsduringeverymedica.onpass.Inanotherstudy,everyinterrup.oncauseda12%increaseinclinicalerrors–thispointstotheimportanceofgivingnursesuninterrupted.meandspace.Physicalremovalofmedica.onfromcertainseRngsisyetanotherwaytosupportsafety.Anexampleofthisistheremovalofconcentratedpotassiumfromclinicalunits,butwiththeaddedannoyanceofhavingtogofinditororderitupwhenitisneeded.Placingpa.entswithsimilaracuitylevelsonthesameunitisyetanotherwaytosortthephysicalenvironmenttosupportsafety.

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Tools&technologyprovideadownstreamlayerof“Swisscheese”betweenanurseandapoten.allyfatalmistake.Smartpumpsareagreatexampleofdownstreamopportunitytocatcherrors.Otherexamplesincludemakinginforma.onreadilyavailableviatablets,computersonwheels,smartphones,PDAs–andthisshouldapplytobothnursesANDpa.ents.CPOEwithdecisionsupporthasbeenshowntoreducemedica.onerrorby55%,butithasalsobeenshowntocreatenewerrorsifnotwelldesignedandimplemented–forexample,aprescribercanaccidentallychoosepenicillininsteadofPenicillaminefromanalphabe.caldropdownbox.BCMAbarcodingdoeswork–onestudyreportedadecreaseinerrorby50%.Interes.ngly,nurseshavetheimpressionittakestoomuch.me,but.mestudieshaveshownthisini.alimpressiontobeincorrect.RFID–radiofrequencyidtagsaswellasVoiceac.vatedmicrophonesonnamebadgesareotherexamplesofsafetysolu.ons.Youwillseesomeitemsonmul.plelistsbecausetheyareimportantatsomanylevels–HFE,FMEAandRCAareallimportanttoolstousetopromotepa.entsafety

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Pa.entsafetysolu.onslieintheareaofteamwork,includingcommunica.onanddealingwithhierarchies(Pronovost,2003).TheVANa.onalCenterforPa.entSafetyhasiden.fiedcommunica.onfailuresinapproximately75%ofmorethan7,000RCAsofadverseeventsandclosecalls.Closedmalprac.ceclaimsfromvariousclinicalseRngsshowedthatineffec.vecommunica.onandteamworkcontributedtomedicalerrorsandpa.entharmin43–70%ofcases.Imen.onedsometeambuildingtoolsintheslideonleadership,butit’sworthrevisi.ng.Communica.onisoverwhelminglythemainrootcauseofsen.nelevents.AnexcellentexampleofwhyweneedtoaddresshierarchiescomesfromTenerife,theworstairtrafficcollisionofall.me,occurringin1977,itkilled583people,andwasduetonooneques.oningawell-respectedpilot.Changesintheairlineindustryinresponsetothiseventhaveledtoaremarkablesafetyrecord.Theairlineindustryins.tutedcommunica.onstrainingcalledCrewResourceManagement(CRM),whichteachespilotshowtocreateanenvironmentthatmakesitpossibleforthoselowerontheauthoritychaintoraiseques.ons.YoucanseefromthisgraphfromtheWachter(2012)book,thatpilotswouldwelcomebeingques.onedbyacoworker,whereasnearly50%ofsurgeonswouldnot.Inastudyin2000:Surgeonsperceivedstrongteamwork,buttheteammembersdisagreed.StudieshavedemonstratedthatCRMimprovescultureandoutcomesinhealthcare.AnexampleofhowCRMworks:

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Whatifyouworkinanenvironmentthatdoesn’tu.lizeanyoftheitemsonthepreviousslides?Therearethingstheindividualcandotoreducethelikelihoodofbeinginvolvedinanerror.Asubstan.albodyofknowledgehasindicatedthatnurses’abilitytoprovidesafeandefficientcareisinfluencedbyindividualcharacteris.cs,includingexper.se,experience,educa.on,andpersonalitytraits(Aikenetal.,2011;Kendall-Gallagher,Aiken,Sloane,&CimioR,2011;McHughetal.,2013).IfyouhaveanADN,getaBSN,ifyouhaveaBSN,getanMSN,andwhileyouaregeRngthathighereduca.on,engageinnurseledresearchandentrepreneurship.Ican’ttellyouthenumberof.mesIhavewishedforanursewithsomecomputerbackgroundtodesignanelectronichealthrecord.Weknowwhatgapsthereare,weareinaprimeposi.ontofindsaferwaystomanagepa.entcarewithscien.ficresearch.Getcer.fiedinyourspecialtyarea.Studiesshowthatpa.entshavebeGeroutcomeswhencaredforbynurseswithhigherdegrees,andnurseswithcer.fica.on.Whatresourcesdoyouhave?Askmanagementaboutthecontentpresentedinpreviousslides.Leadershipcancomefromstaffsugges.ons.Studiesalsoshowthathealthcareworkerswhocareforthemselvesarelesslikelytobeinvolvedinanerror.Mul.plestudieshaveshownarela.onshipbetweenfa.gue,exhaus.onandincreasederrorrate(Hughes,2008).NursescanleadthewayinseRngasidethemachoideaofworkingun.lyoudrop.Trainingandorienta.onarethesecondmostcommonrootcauseinsen.nelevents.MakesureyourCEincludessafetytopics.Seekouthighqualitycon.nuingeduca.onprovidedbyexperts.ThereisalotofCEoutthere,andnotallofitisworthyour.meormoney.IhaveareviewofsitesandCEresourcesonmywebsite.YoucansubscribetomanydifferentemailnewsleGersthatwillkeepyouup-to-dateonthelatestpa.entsafetyresearch.AHRQPa.entSafetyNetwork:posts20newresourceseachweek,withasearchablelibrary.OtherhighqualityjournalsincludetheBri.shMedicalJournal(BMJ)qualityandsafetyjournal;theJointCommissionjournalofqualityandpa.entsafety,theJournalofPa.entSafety.TheLucianLeapeIns.tute’sRecommenda.onsforimprovingpa.entsafetyeduca.on,thoughdirectedatphysiciansisalistofwebbasedresources,manyfreeofcharge.Alloftheseresourcesareonmywebsite.Anyopportunitythatarisesforyoutopar.cipateinsimula.on,takeit(Henneman,2010).Askforit.Aircransimulatorshavebeenaroundfordecades–it’soneofthereasonspilotsdosowellunderpressure–theyhaveprac.ced.Therearesomeinteres.ngstudiesoutthereaboutthosewhosurvivedisasters-theyarethepeoplewhohavespent.mevisualizinghowtodealwithanega.vesitua.on,andevenmoreuseful?Simula.ontrainingforthosenega.vesitua.ons.Don’tbethatpersonwhofreezesunderpressure.Haveyouheardofthechecklistmanifesto(Gawande,2010)?Innursingthereisthisold-schoolcultureofmemorizingeverything,eventhoughwenowknowthatthesafestwaytodealwithahugeamountofinforma.onistohavethatinforma.oninareadilyavailable,trustedsource.RecallIstatedtheimportanceofhavingproceduresthatareeasytofindandfollow?Soonentherearen’tanyintheworkplace.Youwillfindtheminnursingschoolseverywhere,butsomehowwhenwetransi.ontowork,thereisthisideathatwe“shouldn’tneedthem”.Checklistsreducetheriskforerror(Haynes,2011).Justlookatthesafetyrecordofavia.onsincetheybeganusingthem.Ifyourins.tu.ondoesn’thavethem,makethemyourselfandusethem.AsIpreviouslydiscussed,theKeystoneICUprojectinMichiganusedachecklistofevidence-basedinterven.onstoreducecentrallinebloodstreaminfec.onsinICUpa.ents.Thisresultedinastoundingimprovement,withmanyunitselimina.ngCLABSIsformonthsata.me.Another,thesurgicalsafetychecklist,hasshownreduc.oninwrongsitesurgeriesacrossavarietyofseRngs.Otherexamplesincludevariousbundles,suchastheCatheter-AssociatedUrinaryTractInfec.onorCAUTIbundle,wherewehaveseensignificantreduc.onininfec.ons.Thelastitemonthelististospeakup.The10%ofhealthcareworkerswhoconfidentlyraisecrucialconcernsobservebeGerpa.entoutcomes,workharder,aremoresa.sfied,andaremorecommiGedtostayingintheirjobs.Ifmorehealthcareworkers

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Icon.nuetobesurprisedathowtabooitistosuggestapa.ent,orpa.entcenteredcharacteris.csmightbepartofthereasonforanerror.Partofthereasontofocusonpa.entsistheincreasinglycomplexproblemsourpa.entshave.Wearekeepingpeoplealivewhowouldmostcertainlyhavedied20yearsago.Withthatincreaseincomplexitycomesanincreaseinriskforerror.IfIhadtosummarizewhatnursingisinonesentenceitis“nursesknowthepa.ent”–andyoucanuseapa.entchecklisttoincreaseyourawarenessofpa.entcharacteris.cs.Itises.matedthattheaverageICUpa.enthas1.7errorsperday(Donchin,2003).Itiscrucialwhenpa.entshavelanguagebarriersthatweobtainqualifiedtranslators.Non-englishspeakinghave30%higheroddsof30-dayreadmissiontothehospital.Youcanuseafamilymemberforsocialinterac.onsonly.Translatorsarenowavailablebyphone–usethem.Otherbarriersincludepoorhealthliteracyandlearnedhelplessness.36%ofUSadultsin2003hadlimitedhealthliteracy–usespeakup”,“teachback”or“askme3”topromptpa.entstoengageintheirhealthcareexperience.Allhealthinforma.onmustbeat5thgradelevelorlower,andeventhatmaynotbesimpleenough.Specificallyiden.fypa.entsathighriskformedica.onerror–thoseonhighalertmedica.onslikeinsulin,heparin,Milrinone;thosewithmul.plemedica.ons,orpolypharmacyisalsocauseforincreasedalertness.Considergivingadischargechecklisttopa.entsandfamiliesatdischarge,includingtheques.on:“hasaproviderreviewedyourmedica.onswithyou?”it’sawaytoempowerthemandasafetycheckforyou.Beawarethat15%ofdischargedpa.entshavediscrepancyinmedica.onlist.Encourageyourpa.entstobringallmedica.onstoallvisits.Pa.entsathigherriskarethosewhoare85yearsofageorolder,withlowbodyweightorbody-massindex,morethan6ac.vechronicmedicaldiagnoses,atypicalpresenta.onofillness,5ormoremedica.ons,ormorethan12medica.ondosesperday,mul.plehealthprovidersprescribingdrugs,recenthospitaldischarge,historyofpreviousadversedrugevent,impairmentincogni.on,vision,hearing,ordexterity.Consideralsoerrorscausedbypa.ents–¼ADEcausedbypa.enterror:let’sgivethemcheckliststouseaswell.Inpar.cular,pa.entsareoneninvolvedinerrorsrelatedtoadherencetomedica.ons.Factorsinfluencing

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Therehavebeenpocketsofsuccess.Throughoutthispresenta.onIhavegivenyouinterven.onsthathavedocumentedsuccess:CPOE,Smartpumps,communica.onstrategies,increasededuca.onofnurses,cer.fica.on–andyetdespiteallofthesesmallsuccesses,overalltherehasbeennochangeinpa.entharmsincetheIOMreportin2000.

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Pleaseconsidercontribu.ngtothediscussion–visitmywebsiteforadiscussionboardonthisCE,aswellasmanyothers.Mysitehasgatheredallthelatestpa.entsafetyresourcesinoneplaceforyourconvenience.TakealookatthetoolsIhavepostedandconsidersharingthemwithcolleagues,familymembersandpa.ents.Iencourageandneedfeedback,sopleasecontactmeviasocialmediaorthroughmywebsitetomakesugges.ons,cri.cismsandrequests.Email:safetyfirstnursing@gmail.comTwiGer:@safetyfirstnrsFacebook:safetyfirstnursingLinkedIn:safetyfirstnursing

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