Transcript Safety:

Safety:
It’s Everybody’s
Business
Virginia Ingram, MSN, RN
[email protected]
Patient Safety Officer
University of Mississippi Medical Center
Too fast….too far down the runway!
“Most errors are made by
good but
fallible people, working in a
challenged and imperfect
system.”
Error is Inevitable Because of
Human Limitations
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Limited memory capacity – 5-7 pieces of
information in short term memory
Negative effects of stress – ↑ error rates
Negative influence of fatigue and other
physiological factors
Limited ability to multitask – cell phones and
driving
Human Error is Also Inevitable
Because:
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Safety is often assumed, not assured
Culture of the expert individual –
mistakes not allowed
AND…….
Complex, unsafe systems
THEN WE HAVE HUMAN JUDGMENT
Oops! I forgot to set the Brake!
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Copyright © 1997-2005 AirDisaster.Com. All Rights Reserved.
What can we learn from the
Airline Industry?
Before intervention, 70% of air
crashes involved human error rather
than failures of equipment or
weather
Crew Resource Management
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Focus on teamwork, communication,
flattening hierarchy, managing error,
situational awareness, decision making
Non-punitive reporting of near misses
Very open culture with regard to error and
safety
PATIENT SAFETY
Without
Safety,
there is no
Quality.
What is Patient Safety?
In its simplest form,
patient safety is
prevention of harm
to patients.
We are all in the
business of Patient
Safety!!!!
The Legal Fallacy of the
Low Risk Patient
There are NO LOW RISK
patients! Most medical legal
claims come from low risk
patients with poor outcomes !
IT STARTED WITH THE IOM REPORT
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NOVEMBER 1999
KEY FINDINGS:
PREVENTABLE MEDICAL ERRORS CAUSE
44,000-98,000 DEATHS/YEAR IN U.S.
 ERRORS OCCUR BECAUSE OF SYSTEM
FAILURES
 PREVENTING ERRORS MEANS
DESIGNING SAFER SYSTEMS OF CARE
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JCAHO Patient Safety Goals
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Patient Identification
Communication among caregivers
Medication Safety
Infusion Pumps
Healthcare Acquired Infection Prevention
Medication Reconciliation
Falls Prevention
Universal Protocol
Labeling of Medications
Clinical Alarms
Sentinel Events
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Suicide of any individual receiving care or within 72 hours of discharge
Abduction of any individual receiving care, treatment or services
Wrong Site, Wrong Patient Surgery
Incompatible blood transfusion, hemolytic reaction incompatible
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Death from hospital infection
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Rape
Retained foreign object unintended retention of a in an individual
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Adverse Patient Occurrences warranting expanded investigation
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blood
or major permanent loss of
function associated with health-care acquired infections
after surgery or other procedure
What Must We Do?
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Create Culture of
Safety
Safety is at the
center of all
efforts!
Safety is Everybody’s Business
Commitment
and
participation of ALL
employees and staff
 Leadership
Safety
Walkarounds
What Else Should We Do?
 Encourage
error reporting in a
Non-punitive system
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Help staff understand risk, accept responsibility
for harm, lead efforts to prevent harm
Recognize errors as opportunities for reducing
risk
Teach staff how error reports help to track/trend
safety issues and improvement of processes
Don’t tolerate cover-ups
Support employees involved in serious errors
Perform Root Cause Analyses whenever indicated
Why Is This Hard ?
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Trained to be perfect — knowledge and
competence are equated with the absence of error
Medical culture rewards perfection and frowns
upon error
Individual agency — fix the person and the
problem goes away
Don’t Forget to Improve
Communication and Team Work
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Focus on common goal of safe patient care
Promote teamwork training
Standardize Communication (SBAR)
Apply Crew Resource Management techniques
 Use
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3rd person when communicating “WE”
Develop checklists
 Hand-offs,
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procedures
Initiate teamwork training in professional
schools, residency programs
Of Course, Include Patients and
Families in Patient Safety
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Empower patients and
families to actively
participate in care
Include patients and
families on safety teams,
in safety walk arounds
Establish patient
advocacy groups to
advise leaders
Of Course, Include Patients and
Families in Patient Safety
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Empower patients and
families to actively
participate in care
Include patients and
families on safety teams,
in safety walk arounds
Establish patient
advocacy groups to
advise leaders
Measure Results and Monitor
Progress
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CMS Quality Metrics
www.cms.hhs.gov/quality/hospital/PremierMeasures
AHRQ Patient Safety Indicators www.ahrq.org
JCAHO National Patient Safety Goals www.jcaho.org
IHI 100,000 Lives Campaign www.ihi.org
NQF safe practices www.qualityforum.org
National Patient Safety Foundation www.npsf.org
Leapfrog initiatives www.leapfroggroup.org
FMECA www.jcaho.org
Internal and External Benchmarks www.qiproject.org
www.nursingquality.org
What Hinders a Patient Safety
Program?
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Hierarchy / power distance
Failure to communicate
Lack of common mental model
Not having a voice
Lack of respect
Fear of retribution
Up, Up, and Away with Patient
Safety