Transcript Science of Safety - K-HEN

Title: The Science of Safety
Armstrong Institute for Patient Safety and Quality
Presented by: David A. Thompson, DNSc, MS, RN
Title: Associate Professor
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
Learning Objectives
• To recognize that every system is designed to
achieve the results it gets
• To identify the basic principles of safe design
that apply to both technical and team work
• To discuss how teams make wise decisions
RAND Study Confirms Continued Quality Gap
Condition
% of Recommended Care Received
Low back pain
68.5
Coronary artery disease
68.0
Hypertension
64.7
Depression
57.7
Orthopedic conditions
57.2
Colorectal cancer
53.9
Asthma
53.5
Benign prostatic hyperplasia
53.0
Hyperlipidemia
48.6
Diabetes mellitus
45.4
Headaches
45.2
Urinary tract infection
40.7
Hip fracture
22.8
Alcohol dependence
10.5
1. McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.
The Problem is Large
• In U.S. Healthcare system
– 7% of patients suffer a medication error 2
– On average, every patient admitted to an ICU suffers an adverse event 3,4
– 44,000- 98,000 people die in hospitals each year as the result of medical errors 5
– Nearly 100,000 deaths from HAIs 6
– Estimated 30,000 to 62,000 deaths from CLABSIs 7
– Cost of HAIs is $28-33 billion 7
• 8 countries report similar findings to the U.S.
2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995
3. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.
4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.
5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.
6. Klevens M, Edwards J, Richards C, et al., PHR, 2007
7. Ending Health Care-Associated Infections, AHRQ, 2009.
How Can These Errors Happen?
• People are fallible
• Medicine is still treated as an art, not science
• Need to view the delivery of healthcare as a
science
• Need systems that catch mistakes before
they reach the patient
Understanding the Science of Safety
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
How Can We Improve?
Understand the Science of Safety
• Every system is perfectly designed to achieve the results it gets
• Understand principles of safe design
– standardize, create checklists, learn when things
go wrong
• Recognize these principles apply to technical and team work
• Teams make wise decisions when there is diverse and independent
input
Caregivers are not to blame
System Failure Leading to This Error
Communication between
resident and nurse
Inadequate training
and supervision
Catheter pulled with
Patient sitting
Patient
suffers
Lack of protocol
For catheter removal
Venous air embolism
8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.
9. Reason J, Hobbs A., 2000.
System Factors Impact Safety
Institutional
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
10. Adapted from Vincent C, TaylorAdams S, Stanhope N., BMJ, 1998.
Evidence Regarding the Impact of ICU
Organization on Performance
• Physicians11
• Nurses12
• Pharmacists13
11. Pronovost P, Angus D, Dorman T, et al., JAMA, 2002.
12. Pronovost P, Dang D, Dorman T, et al., ECP, 2001.
13. Pronovost P, Jenckes M, Dorman T, et al., JAMA, 1999.
Fatal Aviation Accidents per
Million Departures
14. Statistical Summary of Commercial Jet
Airplane Accidents, Aviation Safety
Boeing Commercial Airplanes, July 2009.
Principles of Safe Design
• Standardize
– Eliminate steps if possible
• Create independent checks
• Learn when things go
wrong
–
–
–
–
What happened
Why
What did you do to reduce risk
How do you know it worked
Standardize
Line Cart Contents – 4 Drawers
Eliminate Steps
Create Independent Checks
Principles of Safe Design Apply to
Technical and Team Work
© The Johns Hopkins University and The Johns
Hopkins Health System Corporation, 2011
ICU Physicians and ICU RN
Collaboration
% of respondents reporting above adequate
teamwork
100
90
80
70
60
50
40
30
20
10
0
90%
54%
RN rates ICU PhysicianKP L&D
ICU Physician rates RN
17. ICUSRS Data from Needham D, Thompson D,
Holzmueller C, et al., Crit Care Med, 2004.
Train & Coach Adaptive Team
Behaviors
• Leadership
– Delegation
– Resource management
– Modeling good teamwork skills
• Communication
– Closed-loop communication
– Using clear, structured communication
• Mutual Support
– Task assistance
– Conflict resolution
– Feedback
• Situation Monitoring
– Shared mental models
– Cross-monitoring
TeamSTEPPS® Competency Framework
Teamstepps.ahrq.gov
Team Training: Does it work?
• Team training is a strategy for systematically
improving teamwork competencies: the
knowledge, skill, and attitudes (KSAs) underlying
effective teamwork.
• Team training significantly improves team1:
– Cognition (ρ = .42)
• Shared mental models
– Behavioral process (ρ = .44)
• Communication, coordination, collaboration
– Affect (ρ = .35)
• Mutual trust, collective efficacy
– Performance outcomes (ρ = .37)
• Task outcomes, satisfaction, viability
1Salas
et al., 2008
But, Does it Work in Healthcare?
• Learner reactions are positive 1,2
• Learning occurs 1,2
• Behavior change in transfer
environment occurs.1,2
• Improved efficiency in clinical
processes3-6
• Improved clinical outcomes7,8
1Rabøl
et al., 2010
2Weaver et al., 2010
3Sissakos et al., 2009
4Wolf et al., 2010
5Capella
et al., 2010
et al., 2011
7Mann et al., 2006
8Neily et al., 2010
6Deering
TeamSTEPPS®
Communication is…
• The process by which information is exchanged
between individuals, departments, or
organizations
• The lifeline of the
Core Team
• Effective when it
permeates every
aspect of an
organization
Assumptions
Fatigue
Distractions
HIPAA
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Basic Components and Process of
Communication
16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.
CUSP & Teamwork
• Teamwork tools:
–
–
–
–
–
–
–
Call list
Daily goals
AM briefing
Shadowing
Observing rounds
Learning from defects*
TeamSTEPPS®
7/17/2015
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
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Armstrong Institute for Patient Safety and Quality
TeamSTEPPS®
Standards of
Effective Communication
• Complete
– Communicate all relevant information
• Clear
– Convey information that is plainly understood
• Brief
– Communicate the information in a concise manner
• Timely
– Offer and request information in an appropriate timeframe
– Verify authenticity
– Validate or acknowledge information
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TeamSTEPPS®
Communication Challenges
•
•
•
•
•
•
•
•
•
Language barrier
Distractions
Physical proximity
Personalities
Workload
Varying communication styles
Conflict
Lack of information verification
Great
Opportunity for Quality and
Shift change
Safety
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TeamSTEPPS®
Teamwork Actions
• Communicate with team members in a
brief, clear, and timely format
• Seek information from all available
sources
• Verify and share information
• Practice communication tools and
strategies daily (SBAR, call-out, checkback, handoff)
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Teams Make Wise Decisions When There is
Diverse and Independent Input
• Wisdom of Crowds
• Alternate between convergent and divergent
thinking
• Get from the dance floor to the balcony level
18. Heifetz R, Leadership Without Easy Answers,1994.
Recap
• Develop lenses to see systems
• Work to standardize one process
• Infuse these principles of standardization and
independent checks in other processes
Works Consulted
1.
McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United
States. N Engl J Med. 2003;348 (26): 2635-45.
2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse
drug events. JAMA. 1995;274(1):29-34.
3. Donchin Y, Gopher D, Olin M, et al., A look into the nature and causes of human errors in the
intensive care unit. Crit Care Med. 23:294-300,1995.
4. Andrews LB, Stocking C, Krizek T, et al., An alternative strategy for studying adverse events in
medical care. Lancet. 349:309-313,1997.
5. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington,
DC: National Acad Pr; 1999.
6. Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections and Deaths in
U.S. Hospitals, 2002. PHR.122:160-166,2007.
7. Ending Health Care-Associated Infections, AHRQ, Rockville,MD, 2009.
http://www.ahrq.gov/qual/haicusp.htm.
8. Pronovost P, Wu A, Sexton J, et al. Acute decompensation after removing a central line:
practical approaches to increasing safety in the intensive care unit. Ann Int Med.
2004;140(12):1025-1033.
9. Reason J, Hobbs A. Managing the risks of organizational accidents. Burlington, VT: Ashgate
Publishing Company, 2000.
10. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical
medicine. BMJ. 1998; 316: 1154–7.
11. Pronovost P, Angus D, et al. Physician staffing patterns and clinical outcomes in critically ill
patients: a systematic review. JAMA. 2002;288(17):2151-2162.
12. Pronovost P, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for
complications after abdominal aortic surgery. Effective clinical practice: ECP. 2001;4(5):199206.
Works Consulted
13. Pronovost P, Jenckes M, Dorman T, et al. Organizational characteristics of intensive care units
related to outcomes of abdominal aortic surgery. JAMA. 1999;281(14):1310–7.
14. Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations 1959-2008.
Boeing News Releases/Statements. July 2009. Aviation Safety Boeing Commercial Airplanes, Web. 21
Jan 2010. <www.boeing.com/news/techissues/pdf/statsum.pdf>.
15. Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. New Engl J Med. 2006;355(26):2725-32.
16. Dayton E, Henriksen K. Communication Failure: Basic components, contributing factors, and the call for
structure. Jt Comm J Qual Patient Saf. 2007; 33(1): 34-47.
17. Needham D, Thompson D, Holzmueller C, et al. A system factors analysis of airway events from the
Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004;32:2227-33.
18. Heifetz R, Leadership Without Easy Answers, President and Fellows of Harvard College,1994.
[email protected]
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Armstrong Institute for Patient Safety and Quality