Transcript IMPACT Leadership Meeting June 16

Quality Colloquium
August 22, 2005
REDUCTION OF ADVERSE
DRUG EVENTS
Kathy Haig
Director Quality Resource Management
Risk Manager/Patient Safety Officer
OBJECTIVES
Introduce process changes that contribute to
reduction of adverse drug events
Discuss the impact of culture on medication
event reduction efforts
Review tools used in process improvement
collaborative
Learn about Medication Reconciliation
OSF ST. JOSEPH
MEDICAL CENTER
Located in Bloomington, Illinois
Serves a community of 100,500 people
Licensed for 157 beds
Provides Open Heart Surgery Services
Started “Beating Heart” Program in 1999
5 Hospital-Owned Physician Office Practices
Urgent Care Center
Licensed as a Level II Trauma Center
GOALS
Maintain a cultural survey score above 4
Involve patients with safety
Conduct 3 phases of med reconciliation
Decrease the Dispensing and Ordering FMEA
Promote Dosing Service for Anticoagulants
Deploy Pharmacy Based Order Sets
Comply with JCAHO Patient Safety Goals
Safety tool kit (RCA, FMEA, Human Factors,
CAS, TRM)
ADE’S / 1000 DOSES
OSF St. Joseph Medical Center
Events/1000 days
Events/1000 Days
250
225
200
175
150
125
100
75
50
25
0
SJMC
J u J u Au Se O No De J a Fe M Ap M
n- l-0 g - p - ctn
v
c
b a
r a
04 4
04 04 04 -04 -04 -0 5 -05 r-05 -05 y -05
Date
Idealized Design of the
Medication System
Key Areas of Focus
Culture
Reconciliation
Dispensing
Ordering
High Risk Medications
Cultural Transformation
Improve Safety Climate or culture
Cultural survey or safety climate score
Focus on harm, not errors
Meaningful, avoids blame game
Focus on process and system
Poor processes; not “bad people”
Focus on communication and teamwork
High Reliability
Medication
System
Safer Core Processes
•CRM
Leadership Driven Culture of Safety
High Reliability Characteristics
Preoccupation with failure
Is 80% good enough?
Deference to expertise
Most knowledgeable takes charge
regardless of role
Ask yourself:
What have I missed today?
What should I have seen that I didn’t?
STARTING THE JOURNEY
CULTURE
System Thinking
 Influenced by patient condition, tasks, staff,
environment, teamwork, management
Collaboration
 Friendly competition; accomplish more, faster
Commitment to Change
 New, better ways; test ideas
Evidence Based
 Order Sets; Protocols
CULTURE
STAFF INVOLVEMENT
Non-Punitive Reporting Policy
Systems Thinking
Focus on harm and processes; not the care provider
Safety Briefings with Employee Feedback
Unit Councils
Staff identify and address unit safety concerns
Involves staff in development of processes
CULTURE
PHYSICIAN ENGAGEMENT
Patient Safety is a standing agenda item
Safety Briefings and Feedback is provided
Monthly updates of PI projects are provided
Root Causes Analyses include physician input
Human Factors included in the Peer Review
Expectations and goals of the organization are
shared
Efforts made to obtain input while being
mindful of the physician’s time
PHYSICIAN INPUT
Ad Hoc team developed process and
protocol for Peri-operative Beta Blockade
Anesthesiologists developed Epidural
Protocol
Pediatricians requested child Med Safety
Brochure for their offices
Internists and CV Surgeons assisted in
development of IV Insulin Infusion Protocol
CULTURE
PATIENT INVOLVEMENT
Satisfaction survey questions for safety
Medication Safety Brochure given to all new
admissions; distributed by physician offices
Community resource collaboration to
encourage patient to keep updated med list
Patient education channel is available 24/7
with information about disease
Community Board serves a dual role as the
Patient Advisory Council
PATIENT SAFETY POSTER
ALSO AVAILABLE IN SPANISH
Be Involved in Your Care
Make sure the nurse checks your armband
before giving you your medicine.
Ask the nurse about medication that is unfamiliar to
you BEFORE you take it.
Make sure the staff and physician washes their
hands before / after providing care to you
MEDICATION
RECONCILIATION
Definition
A process of identifying the most accurate list
of all medications a patient is taking and using
this list to provide care in any setting
It requires comparing the patient’s list of
current medications against the physician’s
admission, transfer and discharge orders.
WHY DO THIS?
Provides the ability to accurately compare
home meds to meds ordered during
hospitalization
Detects medication errors before they
happen
Promotes continuity of care between
different levels of care
Wrong dose, route or frequency may be
prescribed
Important meds may be omitted
RECONCILIATION PROCESS
Med history is completed
Med history is compared with admission medication
orders
Transfer reconciliation is conducted when the patient
moves to a different level of care
Discharge reconciliation compares the meds ordered
during hospitalization with those ordered to be taken at
home
Variances between med history and admission orders is
clarified with the physician
What is included?
 Current home meds, OTC, Herbals
 Includes dose, route, frequency, time of last dose
WHERE TO GET
INFORMATION
Patient or family
Patient’s pharmacy
Previous medical records
Primary care physician’s office
Patient’s medication bottles
BARRIERS
Bureaucracy
Complexity of communication--interruptions
Accountability—staff too busy
Lack of teamwork—office does not have
updated list or nursing home list is confusing
Patient brings in incorrect list
Patient does not take what is marked on the
bottle
Patient does not know names of meds
Patient is unable to tell you
ADMISSION
RECONCILIATION
OSF Healthcare System Performance Goals : SJMC : Pursuing
Perfection In Safety : National Patient Safety-Admission Medication
Reconcilliation : By Month
100%
90%
80%
70%
Percentage
Rate
60%
50%
40%
30%
20%
10%
0%
Goal Admission Reconciliat ion
Admission Reconciliat ion N
Oct 04
Nov04
Dec04
Jan-05
Feb05
M ar05
Apr05
M ay05
100%
100%
100%
100%
100%
100%
100%
100%
19
18
16
18
17
17
16
19
Admission Reconciliat ion D
20
20
20
20
20
20
20
20
Rat e Admission Reconciliat ion
95%
90%
80%
90%
85%
85%
80%
95%
[Oct-04 to Present : Inhouse Data Collection]
Jun-05 Jul-05
Aug05
Sep05
100%
100%
100%
100%
0%
0%
0%
0%
TRANSFER RECONCILIATION
OSF Healthcare System Performance Goals : SJMC : Pursuing
Perfection In Safety : National Patient Safety-Transfer Medication
Reconcilliation : By Month
100%
90%
80%
70%
Percentage
Rate
60%
50%
40%
30%
20%
10%
0%
Goal Transf er Reconciliat ion
Transf er Reconciliat ion N
Transf er Reconciliat ion D
Rat e Transf er Reconciliat ion
Oct 04
Nov04
Dec04
Jan-05
Feb05
M ar05
Apr05
M ay05
100%
100%
100%
100%
100%
100%
100%
100%
5
7
7
6
6
8
8
5
10
10
10
10
10
10
10
10
50%
70%
70%
60%
60%
80%
80%
50%
[Oct-04 to Present : Inhouse Data Collection]
Jun-05 Jul-05
Aug05
Sep05
100%
100%
100%
100%
0%
0%
0%
0%
DISCHARGE
RECONCILIATION
OSF Healthcare System Performance Goals : SJMC : Pursuing
Perfection In Safety : National Patient Safety-Discharge Medication
Reconcilliation : By Month
100%
90%
80%
70%
Percentage
Rate
60%
50%
40%
30%
20%
10%
0%
Goal Discharge Reconciliat ion
Discharge Reconciliat ion N
Discharge Reconciliat ion D
Rat e Discharge Reconciliat ion
Oct 04
Nov04
Dec04
Jan-05
Feb05
M ar05
Apr05
M ay05
100%
100%
100%
100%
100%
100%
100%
100%
18
19
16
20
18
16
17
20
19
19
18
20
19
18
20
20
95%
100%
89%
100%
95%
89%
85%
100%
[Oct-04 to Present : Inhouse Data Collection]
Jun-05 Jul-05
Aug05
Sep05
100%
100%
100%
100%
0%
0%
0%
0%
FMEA—DISPENSING
The Dispensing FMEA has been reduced 66%
Pharmacy reduced/standardized unit stock meds
Pharmacy prepares all non-standard doses
Labels on all IV pumps encourage caution when
stopping the pump to make rate or dose changes
IV Drug Administration Reference matrix directs
dosages, guidelines, monitoring information
An automated dispensing system was installed
Renovation of nursing and pharmacy workspaces to
improve process flow and efficiency
DISPENSING FMEA
C Chart : IHI-ADE : Dispensing FMEA Chart
1800
1600
1400
UC L=1230
1200
Dispe nsing
RPN
Me an=1129
LCL=1028
1000
800
600
400
200
Ne w Info Syste m
Pharmacy Ente rs O rde rs
Pharmacy O n Unit
0
[Jul-01 To Pre se nt : IHI-ADE Data]
FMEA-ORDERING
Hazard Vulnerability Score has been reduced 34%
A Periop-Beta Blocker Protocol was initiated 1/03
Surgical Prophylaxis Antibiotic Protocol developed
Pharmacists assigned to a nursing unit/enter orders
Renal dosing review based on creatinine clearance
Abbreviations
Unapproved abbreviations are on orders sheets
Illegibility
Pharmacists call with any question of the order
Read-Backs
Nurses read back 95% of all telephone orders and
sign with “TORB”
ORDERING FMEA
C Chart : Ordering FMEA Chart
200
UC L=180
180
160
Mean=144
140
120
Haz ard
Vulne rability 100
Score
80
LC L=108
Pharmacy Ente rs O rde rs
60
40
Pharmacy O n Units
20
0
[O ct-02 To Pre se nt : IHI-ADE Data]
HIGH RISK MEDICATIONS
Heparin Nomogram
PCA Protocol with default orders
TPN Protocol
IV Insulin Infusion Protocol
Chemotherapy Order Set
Coumadin dosing service
DVT Protocol
Review of all INR’s above 4 to identify
opportunities in dosing regimens
SIMULATION
“Sim Man” purchased
Simulation lab created
Simulation used for Clinical
Orientation for RN/LPN/US/CNA
Simulation used for annual skills
validation
Simulation used for Root Cause
Analysis
ROOT CAUSE ANALYSIS
Human Factor Triage Questions incorporated
into RCA—approved and applauded by
JCAHO
One RCA resulted in improvements that
prevented care issues in a subsequent trauma
(ED/difficult intubation boxes)
Success of RCA’s spreading—being used
independently by other areas such as OR and
EMS Services to evaluate a “near miss”
SBAR
SBAR Acronym-Situation, Background,
Assessment and Recommendation
Laminated pocket cards including the acronym
have been distributed to all nurses
Posters explaining SBAR have been posted in
clinical areas and stickers have been placed on
phones
Use of SBAR spreading to all areas for any
issue
Medical Staff are encouraged to ask staff to use
SBAR
SBAR POCKET CARD
In the interest of Patient Safety
and to ensure we are giving
complete, accurate information to
the physician, please use the
following acronym to direct the
information we provide:
S
(the current Situation or problem)
B
(a little about the patient’s Background)
A
(your Assessment of the patient)
R
(your Recommendation of what is needed
from the physician)
TEAM RESOURCE MANAGEMENT
Improves team efficiency and effectiveness
Includes multiple concepts
Communication tools—SBAR
Staff assertion
Situational Awareness
Briefings
Debriefings
Red Flags
Initial and refresher training was provided to
staff and physicians
BARRIERS
Limited Resources
Lack of organization/leadership support
Lack of physician buy-in
Resistance to change
Starting too big
Moving too quick
Reluctance to share safety concerns
Multiple projects
Added work instead of replacement
LESSONS LEARNED
Involve the right people
Use rapid cycle tests of change
Simplify processes
Share successes
Don’t recreate the wheel—network with
others
Communicate
KEYS TO SUCCESS
Leadership Support
Make it a win-win situation
Reward and recognize staff
Provide ongoing feedback
Always make patient safety the priority!
Never give up; there is no obstacle that
cannot be overcome!!!
“Safety is like peeling
an onion--the more you
look, the more you find
and each layer makes
you cry”.