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Learning From Defects and
Implementing Daily Goals
Sean Berenholtz, MD MHS
Comprehensive Unit-based Safety
Program (CUSP)
1.
Educate staff on science of safety
2.
Identify defects
3.
Assign executive to adopt unit
4.
Learn from one defect per quarter
5.
Implement teamwork tools
Slide 2
Learning From Defects
Objectives
• To understand the difference between first order
and second order problem solving
• To understand how to address each of the 4
questions in learning from defects
– What happened, why, what will you do to reduce risk,
and how do you know it worked
Slide 4
Case Example
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65 yo M s/p lung resection for cancer
Admit to ICU; discharged to floor POD 1
POD 3 develops hypoxia
Admitted to ICU, intubated
CXR shows extensive left lung collapse
Decision to perform broncoscopy
Slide 5
System Failure Leading to Error
Bronch cart
not stocked
Fatigue
Patient Illness
Patient suffers
Communication between
resident and nurse
Hypoxic arrest
Slide 6
Problem Solving*
• First Order
− Recovers for that patient yet does not reduce risks for future
patients
− Example: You go get the supply or you make do
• Second Order
− Reduces risks for future patients by improving work processes
− Example: You create a process to make sure supplies are
stocked
*Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological
Dynamics that Inhibit System Change. California Management Review, 2003 ;45(2):55-72.
Slide 7
Learning From Defects Tool
• Frontline caregivers are eyes and ears of patient
safety
• Practical investigative tool
• Can be used to investigate events or near misses
• Can also be used in Morbidity & Mortality Rounds,
investigations resulting from sentinel events or
liability claims
• Involves a 4 step structured process
• Guides the user through evaluation of system
factors that may have contributed to an event
Slide 8
4 Questions (steps) to
Learn from Defects
• What happened?
– From the view of the person involved
• Why did it happen?
– Evaluates the defect
• What will you do to reduce the chance it will recur?
– Specific actions needed to reduce the likelihood of
recurrence.
• How do you know that you reduced the risk that it
will happen again?
Slide 9
Step 1. What Happened?
• Construct a brief, concise statement of the “story”
surrounding the incident
• Reconstruct the timeline of the incident or near miss.
• Put yourself in the place of those involved, in the middle of
the event as it was unfolding
• Try to understand what they were thinking when the
event occurred
• Try to view the world as they did when the event
occurred
• Why did they make the decisions they made and take
the actions they took?
Source: Reason, 1990;
Slide 10
Step 2. Evaluate the Defect
• Evaluate the defect by:
– Reviewing and checking all the factors that caused or
negatively contributed to patient harm
– Reviewing and checking all positive factors that might
have reduced or eliminated harm
Slide 11
Probes to Contributing Factors:
Examples
Patient
Was the patient acutely ill? Agitated? Anxious? Aged?
Language barrier? Personal or social issues?
Task
Was a stated policy/protocol or guidelines followed?
Were labs available for decision making?
Caregiver
Fatigue? Lack of experience by care givers? Any
physical or mental health issues with provider?
Team
Were handoffs (verbal or written) clear? Was there a
clearly identified team leader? Were team members
hearing one another’s concerns?
Training and Education
Was established protocol followed? Were caregivers
knowledgeable and competent?
Slide 12
Step 3. What will you do to reduce
the risk of it happening again
• Prioritize most important contributing factors and
most beneficial interventions
• Safe design principles
– Standardize what we do
− Eliminate defect
– Create independent check
– Make it visible
• Safe design applies to technical and team work
Slide 13
What will you do to reduce risk
• Develop list of interventions
• For each intervention, rate
– How well the intervention solves the problem or mitigates
the contributing factors for the accident
– Rates the team belief that the intervention will be
implemented and executed as intended
• Select top interventions (2 to 5) and develop
intervention plan
– Assign person, task follow up date
Slide 14
Rank Order of
Error Reduction Strategies
Forcing functions and constraints
Automation and computerization
Standardization and protocols
Checklists and double check systems
Rules and policies
Education / Information
Be more careful, be vigilant
Slide 15
Step 4. How do you know risks
were reduced?
• Did you create a policy or procedure (weak)
• Do staff know about policy or procedure
• Are staff using the procedure as intended
– Behavior observations, audits
• Do staff believe risks were reduced
Slide 16
Summarize and Share Findings
• Summarize finds
– 1 page summary of 4 questions
– Learning from defect figure
• Share within your organizations
• Share de-identified with others in collaborative
(pending institutional approval)
Slide 17
Examples of where this was applied
• CUSP program
• Critical Care Fellowship Program
• Morbidity and Mortality Conferences
• Anesthesiology residency program
Slide 18
Learning From Defects to Enhance
Morbidity and Mortality Conferences
Defect
Interventions
Fellow 1
Unstable oxygen tanks on beds
Oxygen tank holders repaired or new holders installed institution-wide
Fellow 2
Nasoduodenal tube (NDT) placed in lung
Protocol developed for NDT placement
Fellow 3
Medication look-alike
Education, physical separation of medications, letter to manufacturer
Fellow 4
Bronchoscopy cart missing equipment
Checklist developed for stocking cart
Fellow 5
Communication with surgical services about night
coverage
White-board installed to enhance communication
Fellow 6
Inconsistent use of Daily Goals rounding tool
Gained consensus on required elements of Daily Goals rounding tool use
Fellow 7
Variation in palliative care/withdrawal of therapy
orders
Orderset developed for palliative care/withdrawal of therapy
Fellow 8
Inaccurate information by residents during rounds
Developing electronic progress note
Fellow 9
No appropriate diet for pancreatectomy patients
Developing appropriate standardized diet option
Fellow 10
Wrong-sided thoracentesis performed
Education, revised consent procedures, collaboration with institutional
root-cause analysis committee
Fellow 11
Inadvertent loss of enteral feeding tube
Pilot testing a ‘bridle’ device to secure tube
Fellow 12
Inconsistent delivery of physical therapy (PT)
Gaining consensus on indications, contraindications and definitions,
developing an interdisciplinary nursing and PT protocol
Fellow 13
Inconsistent bronchoscopy specimen laboratory
ordering
Education, developing an orderset for specimen laboratory testing
Am J Med Qual 2009;24(3):192-5.
Evaluations
• “one of the most valuable parts of [their]
fellowship”
• ...their project “improved [their]
understanding of safe systems”
• “it was great to work with colleagues from
other disciplines to improve patient care”
• “changing a system can be difficult, but
[they] are better prepared to address patient
safety defects after fellowship”
Slide 20
Learning from Defects in M&M
Conference
• Select 1 or 2 meaningful cases
• Invite everyone who touches the process including
administrators
• Summarize event
• Identify hazardous systems
• Close the Loop (issue, person, F/U)
• Share what you learn
Slide 21
Sources of Defects
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Adverse event reporting systems
Sentinel events
Claims data
Infection rates
Complications
How is the next patient going to be harmed
Slide 22
Staff Identify Defects
• Survey staff; establish a collection box or envelope
• Identify and group common defects (such as communication,
medications, patient falls, supplies, etc.)
• Summarize as frequencies (i.e., what percent of responses
were for communication)
• QI team reviews data, set the agenda for discussion with
executive partner
Slide 23
Key Lessons
Focus on systems not people
Prioritize
Use Safe design principles
Go mile deep and inch wide rather than mile wide
and inch deep
• Pilot test
• Learn form one defect a month/quarter
• Answer the 4 questions
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Slide 24
References
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Bagian JP, Lee C, et al. Developing and deploying a patient safety program
in a large health care delivery system: you can't fix what you don't know
about. Jt Comm J Qual Improv 2001;27:522-32.
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Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in
patient care. Jt Comm J Qual Patient Saf 2006;32(2):102-108.
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Reason J. Human Error. Cambridge, England: Cambridge University Press,
2000.
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Vincent C. Understanding and responding to adverse events New Eng J Med
2003;348:1051-6.
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Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause
analysis. JAMA 2008;299:685-87.
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Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance
Morbidity and Mortality Conferences. Am J Med Qual 2009;24(3):192-5.
Slide 25
Implementing Daily Goals
Learning Objectives
• To understand the importance of having daily goals
• To understand basics of communication
• To learn how to implement daily goals in your ICU
• To understand that daily goals is a tool to improve
teamwork and communication AND supports
interventions to reduce CLABSI and VAP
Slide 27
Importance of Daily Goals
• People and organizations who create explicit goals and
provide feedback toward goals achieve more than
those who do not
• Rounds generally provider rather than patient centered
• Discussion on rounds is divergent (brainstorming) rather
than convergent (explicit plan)
Slide 28
% of respondents reporting above adequate teamwork
ICU Physicians and ICU RN
Collaboration
ICUSRS Data
Slide 29
Communication Errors
• Communication errors most common contributing factor
for all types of sentinel events reported to The Joint
Commission
• Over 80% of staff responding to the question, “how will
the next patient be harmed” list communication failure
Slide 30
Basic Components and Process of
Communication
Elizabeth Dayton, Joint Commission Journal, Jan. 2007
Slide 31
Daily Goals
• Standardizes communication and creates
independent checks
• Helps ensure diverse input
• Adds convergent thinking to often divergent rounds
• Reduces encoding and decoding errors
Slide 32
Sample
Daily Goals
J Crit Care 2003;18(2):71-75
Slide 33
How to Use Goals?
• Be explicit
• Important questions
– What needs to be done for discharge
– What will we do today
– What is patients greatest safety risk
• Completed on rounds and nurse reads back
• Stays with bedside nurse
• Modify to fit your hospital
Slide 34
Percent Understanding
Patient Care Goals
Implemented patient
goals sheet
Pronovost daily goals
Slide 35
Impact on ICU Length of Stay
Daily Goals
654 New Admissions: 7 Million Additional Revenue
Slide 36
Michigan Keystone ICU
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CRBSI Rate
Median and Mean CRBSI Rat e
Time (months)
Median CRBSI Rate
Mean CRBSI Rate
N Engl J Med 2006;355:2725-32; BMJ 2010;340:c309.
Slide 37
Michigan Keystone ICU
(n=
Infect Control Hosp Epidemiol. 2011;32(4): 305-314
Slide 38
Action Plan
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Present the idea to your local team
Draft a daily goals form
Obtain support from one or more physicians
Monitor number of time physicians are paged
(WIFM)
– Daily goals reduced pages by 80%
• Pilot test on one patient
• Expand
Slide 39
References
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Pronovost PJ, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C.
Improving communication in the ICU using daily goals. J Crit Care
2003;18(2):71-5.
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Dayton E, Henriksen K. Teamwork and Communication: Communication
Failure: Basic Components, Contributing Factors, and the Call for Structure. Jt
Comm J Qual Patient Saf 2007;33(1):34-47.
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Schwartz JM, Nelson KL, Saliski M, Hunt EA, Pronovost PJ. The daily goals
communication sheet: A simple and novel tool for improved communication
and care. Jt Comm J Qual Patient Saf 2008;34(10):608-13.
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Timmel J, Kent PS, Holzmueller CG, Paine L,et.al. Impact of the Comprehensive
Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit.
Jt Comm J Qual Patient Saf 2010;36:252-60.
Slide 40