Transcript Slide 1

Patient Safety
The New Healthcare Discipline
Louisiana Association for Healthcare Quality
Patient Safety Boot Camp
October 17, 2014
Phyllis Ragland, RN, CPHQ, CPPS
Why we are here today!
• Medical Error
– “…an act of omission or commission in planning
or execution that contributes or could
contribute to an unintended result.”
“Isn’t it nice when things just work?”
http://www.youtube.com/watch?v=_ve4M4UsJQo
The New Healthcare Discipline
• Introduction to the new healthcare discipline
of Patient Safety
– Origin and evolution;
• To Err is Human
• Patient Safety & Quality Improvement Act of 2005
– Final Patient Safety Ruling
– Relationship and alignment of Patient Safety,
Quality, Risk Management; and
– the commitment critical to becoming a highly
reliable organization.
• Bedrock of Patient Safety;
Breaking the Cycle of Inaction
“To Err is Human”
The Catalyst for Patient Safety
Errors in
Healthcare: A
Leading
Cause of
Death &
Injury
Creating
Safety
Systems in
Healthcare
Organizations
Building
Leadership
and
Knowledge
for Patient
Safety
Why do
Errors
Happen?
Protecting
Voluntary
Reporting
Systems
from Legal
Discovery
IOM
“To Err is
Human”
Comprehensive
Approach to
Improving Patient
Safety
Error
Reporting
Systems
Setting
Performance
Standards and
Expectations
for Patient
Safety
Protecting Voluntary Reporting
Systems From Legal Discovery
President George W. Bush signs the Patient Safety and Quality Improvement Act 2005 with a
component to create Patient Safety Organizations (PSO) that would provide organizations a new
level of federal protection from discovery through submission of Patient Safety Work Product
and support these organizations with patient safety education and improvement activities.
Defined Error Reporting Systems
• Patient Safety Evaluation System (PSES)
• Mechanism through which information can be collected,
maintained, analyzed and communicated
• Common Formats: Provide standardized definitions
and reporting specifications for the collection of patient
safety data
• Patient Safety Work Product (PSWP)
• Any data, reports, records, memoranda, analyses (e.g. RCA),
or written or oral statements assembled to improve patient
safety and intended for submission to a PSO for Federal
Protection of privilege and confidentiality
• Network of Patient Safety Databases (NPSD)
• Receives, analyzes, and reports on de-identified patient
safety event information with the goal of large-scale
aggregation and analyses to help reduce adverse events
and improve healthcare quality
PSES & PSWP Throughput:
The Inclusion Process
Information assembled
to improve patient safety and
intended for submission to PSO
Patient Safety
Organization
(PSO)
Network of Patient Safety Databases (NPSD)
De-identified Data Transmission
Patient Safety
Work Product
(PSWP)
Federal Protection from Discovery
Patient Safety
Evaluation System
(PSES)
Completed PSWP Transmission to PSO
Mechanism for collecting,
managing, & analyzing
patient safety data
CMS Survey & Certification
& Patient Safety Initiatives
• “CMS should further influence hospitals
to reduce adverse events through
enforcement of the conditions of
participation. This could include more
closely examining patient safety issues
through the survey and certification
process…”
Thomas E. Hamilton, Director
Survey & Certification Group
Center for Clinical Standards &
Quality Centers for Medicare &
Medicaid 5th Annual Meeting of
PSOs
CMS Survey & Certification
& Patient Safety Initiatives
• “AHRQ Common Formats - Information for Hospitals
and State Survey Agencies (SAs) - Comprehensive
Patient Safety Reporting Using AHRQ Common
Formats”
• Memo # 13-19-HOSPITALS Dated March 15, 2013
• The CoP for Quality Assessment and Performance
Improvement (QAPI) requires hospitals to track adverse
patient events
• However, HHS reports that hospitals fail to identify most
adverse events
• Use of Common Formats may help meet tracking
requirements
• Hospitals using Common Formats and adept at analysis
will be better positioned to meet QAPI requirements
• Surveyors are encouraged to become familiar with
Common Formats
CMS Survey & Certification &
Patient Safety Initiatives
• CMS Surveyors will be evaluating
Adverse Event Oversight Systems
• Program Design + Scope
• Feedback Systems + Learning
• Adverse Events Reporting:





Reported
Tracked
Investigated
Analyzed
Used
5 Characteristics of
High-Reliability Organizations
1. Preoccupation with failure
2. Reluctance to simplify
interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Deference to expertise
http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-howto-hardwire-each-in-your-organization.html
Building Leadership and Knowledge
for Patient Safety
• Fostering a culture of safety and learning as
a priority for everyone that works in the
hospital
• Mitigating Risk and Injury Strategies
through identification and implementation
of proactive patient safety strategies
• Planning and providing services that meet
the patient needs
• Making available resources – human,
financial, and physical – for providing safe
and quality care, treatment and services
Leaders Framework for Patient Safety
•
Defined scope of the Patient Safety Program
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Procedures for immediate response to system or process
failures
•
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Occurrences that reach the patient inclusive of Sentinel Events
Near Misses
Unsafe Conditions
Caring for the affected individual
Containing risk to others
Preserving factual information for analysis
Disclosure
System for blame-free internal reporting of a system or
process failure and proactive risk assessment
Support system for staff members who have been involved
in an adverse or sentinel event (Second Victim)
Communication/Reporting avenues for dissemination of
lessons learned from RCA/FMEA/Proactive Risk Assessments
and event reporting activities
Bedrock Of Patient Safety
New
Healthcare
Discipline
Science of
Patient Safety
Driving Change through
Measurement
Mitigating Risk & Injury Using
Data & Deep-Dive Analysis
Redesigning for Patient Safety
Comprehensive Approach To
Improving Patient Safety
Governing
Board
Leadership
Organizational
Chart
(Job Functions, Line Authority
& Policy/Procedure in Day-toDay Operations and
Provision of Care)
PATIENT
SAFETY
Committee
Structure
(Planning, Designing,
Implementing &
Evaluating Initiatives)
Organizational Infrastructure
Mission/Vision/Values
Relationship of Patient Safety to
Risk & Quality Management
Synergy of Patient Safety,
Quality and Risk Management
Creating Safety Systems in Healthcare
Organizations
• Maintain a culture of safety that supports a
safe and just culture
• Identify organizational champions
• Deploy and sustain patient safety strategies
• Determine key drivers for patient safety
programs
• Ensure the adoption of current and
advancing safety technologies
Creating a Culture of Safety
• Administer valid survey to assess culture of
safety.
• Benefits:
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Raise staff awareness about patient safety
Diagnose/Assess current status of organizational culture
Target low-performing domains for improvement
Identify domains of best practice to spotlight
Examine trends in culture over time
Evaluate the cultural impact of patient safety initiatives
Compare internal and external status and progress
• Capitalize on “near-miss” reporting to assess
culture of safety
• Set goals and develop actions to increase “nearmiss” reporting
http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html
2012 AHRQ Patient Safety Culture Survey 12 Composite-Level Results
http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html
Patient Safety Awareness Ideas
• Establish a Planning Team
• Team member selection (Utilize/Designate
Patient Safety Champions)
• Timeframe for Kick Off
• Solicit Leadership Support
• Establish Patient Safety Awareness Theme
• Patient Safety Champion Kick Off
• Training program
• Patient Safety Fair
• Awareness Signage
• Success stories (Staff Posters, presentations)
• Display topic-specific Patient Safety data
graphics/status (include Culture of Safety results)
Patient Safety Awareness Ideas
• Facility Open House
• Invite Community
• Reward/Recognition Incentives for Staff
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•
•
Unit Award
Gift Shop Gift Certificates
Pizza Parties
Candy/Popcorn
• Lunch & Learn Patient Safety Activities
• “Learn to Report & Report to Learn”
• Patient Safety Awareness Simulation Center
• “House of Horrors”
• Publish/Present Staff Patient Safety Stories
Science of Patient Safety
• Essential Components of Patient Safety for creating
a culture of safety & Mitigating Risk and Injury
– Concepts
• System thinking and complexity
• Human Factors
– Attitudes
• Teamwork
• Accountability
– Skills
• Error Causation
• Leadership
• Change Management.
What is Patient Safety?
• “A discipline in the healthcare profession
that applies safety science methods
toward the goal of achieving a
trustworthy system of health care
delivery”….as well as…
• “an attribute of health care systems; it
minimizes the incidence and impact of
adverse events and maximizes recovery
from such events.”
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
How is Patient Safety achieved?
Applying the Safety Sciences
Attitudes
Teamwork, Accountability,
Professionalism,
Transparency, Just Culture, Etc.
Concepts
Science of Error Causation,
System Thinking, Complex
Systems, Human Factors,
Applied Informatics, etc..
Skills
Error Analysis, Leadership, Change Management, etc..
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
Patient Safety Complexity
• Who is accountable and responsible for
Patient Safety?
https://www.youtube.com/watch?v=cEGkrOtzqWo
System Thinking & Complexity
• System Thinking
– “A conceptual framework, a body of knowledge and
tools that has been developed over the past fifty
years, to make the full patterns clearer, and to help
us see how to change them effectively.”
• Complexity
– “A series of unpredictable dynamic systems. The
more complex, the more unpredictable dynamic
systems are probable.”
• System Failures
– “Attempting to solve complex issues without a
systems thinking approach may lead to unintended
consequences, despite the best intentions.”
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
http://www.seedsystems.net/clientuploads/Slide1.jpg
System Thinking & Complexity:
Example of Patient Safety Initiative
Restraint Management Key Functions
Leadership
Clinical Practice
Information
Management
Staff Education
Quality
Measurement &
Improvement
Activities
Leadership
Key Responsibility & Accountability Functions
Human
Resources
Supply &
Equipment
Clinical Staffing
Procurement
Data Collection &
Analysis (Time)
Supply Levels
Medical
Center
Coordination
Information Mgt
Support
Medical Center
Philosophy
Mission/Vision
& Values
Culture
Designated
Oversight
Why does the discipline of Patient
Safety exist?
“The high prevalence of avoidable adverse
events…”
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
What is the nature of Patient Safety?
“A subject within healthcare quality…”
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
What is the essential focus?
“Applying safety sciences to healthcare
systems and processes…”
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
What are the properties of
Patient Safety?
“…designed for the nature of illness/ condition
and is dependent on understanding and
learning from errors and system failures…”
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
Where does Patient Safety
occur?
“…Point of care: Medical Unit, Intensive Care,
Operating Room, Radiology, Outpatient Unit,
Admissions, etc.…”
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
How does Patient Safety emerge?
Culture
of
Safety
Communication
Teamwork
Just
Culture
Patient
Centered
Leadership
Evidence-based
http://www.ahrq.gov/downloads/pub/advances2/vol1/Advances-Emanuel-Berwick_110.pdf
Comprehensive Unit Safety Program
(CUSP) – Change Management Tool
• Definition:
– CUSP organizes change teams to improve processes by
addressing system-level factors that impact patient
safety
• Benefits:
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–
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Integrates with range of safety models and initiatives
Empowers staff
Leads to Shared Mental Model
Expedites change through improved communication
and collaboration
– Can be applied at any level and utilized by any group
– Enables wide selection of safety tools and approaches
http://www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit/
Why Do Errors Happen?
What you
don’t know
CAN
hurt you!
Swiss Cheese Model
Near Miss or Unsafe Condition
Incident
Clinical Groupings of Errors
• Diagnostic
• Error or delay in diagnosis
• Failure to employ indicated test
• Failure to act on results of monitoring or testing
• Treatment
• Error in the performance of an operation, procedure or test
• Error in administering the treatment
• Error in the dose or method of using a drug
• Avoidable delay/failure to treatment or respond
• Preventive
• Failure to provide prophylactic treatment
• Inadequate monitoring or follow-up treatment
• Other
• Failure to communicate
• Equipment failure
• Other system failures
NQF List of “Never Events”
resulting in death/serious disability
• Care Management Event
• Medication Error
• Environmental Event
• Restraint Usage
• Patient Protection Event
• Elopement
• Potential Criminal Event
• Assault (Sexual or Physical)
• Product or Device Event
• Contaminated Drugs
• Radiological Event
• MRI
• Surgical Events
• Retained Foreign Object
Human Factors
Things to keep in mind!
• We ALL make mistakes!
• Generally, human error is the result of
factors or circumstances beyond our
control.
• Any system or process that is dependent on
human perfection is intrinsically flawed.
Human Factors
“An explosion that killed seven Marines during a training exercise at an Army depot in Nevada in March
was caused by human error, a military investigation has found. The blast, which also injured eight other
service members, happened when a Marine operating a mortar ‘did not follow correct procedures,
resulting in the detonation of a high explosive round at the mortar position,’ according to a news
release from 1st Lt. Oliver David, a spokesman at the Marine Corps Base Camp in Camp Lejeune, N.C”
Human Factors
• Multiple factors that contribute to
Human Error
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Failure to communicate
Lack of effective training
Lapse in memory
Lack of attention
Fatigue
Equipment that is poorly designed
Noisy or poorly designed environment
Person factors
Inadequate technology
No resources/guidelines
Complexity of task
Mistake-Proofing for
Human Factors
• Design strategies to prevent errors
• Automation
• As appropriate
• Incorporate “forcing functions”
• Standardization
• Reduce need to relay on memory
• Develop checklists
• Modeled by policy/procedure/guidelines
• Incorporate into medical record documentation, as
appropriate
• Reduce the number of process steps
• Handoffs
• Patient Movements
• Ensure redundancy (double checks)
• High risk processes
Let’s take a break!
Next Up:
Driving Change through Measurement
Driving Change through Measurement
• Types of measurement techniques used to examine
results and determines effectiveness of patient
safety efforts
• Discussions around use of internal and external
regulatory requirements to conduct an
organizational data inventory to identify areas for
actions
• Skills needed to conduct error analysis, conduct
deep dive data analysis of event data and identify
targeted strategies to improve the safety of
patients.
Assessing Data Quality & Validity
• Key data assessment questions:
– What data do we have? Is there an inventory list?
– Who is collecting the data?
• Duplicate data collection occurring?
• Utilizing the same standardized tool?
–
–
–
–
What is the source of the data?
Where is it housed?
What is its scope (starting point to end point)?
What is its quality (standardized collection tools)?
• Is there confusion in usage, meaning and expectations?
• Is there an inter-rater reliability process?
– Who has oversight/responsibility for the data?
– What reports are generated?
• Inclusive of Action Plans/Responsible Party/Due Dates
– Who receives the reports?
Data Inventory Definition
• Definition
– A structured and comprehensive way of identifying the
organizational data asset.
• Purpose
– To assure collection, analysis, reporting of critical data
required by both internal and external
requirements/directives by appropriate groups for
performance improvement activities and decision-making.
• Benefits
– Identify inconsistencies, omissions, duplications, and errors
in patient safety data collection, analysis and reporting.
– Communicate a comprehensive overview of patient safety
data collection, analysis and reporting for an organizational
shared mental model.
Steps in Conducting a Data Inventory
• Communicate activities to Leadership/Manager/Committees/
Action Teams
• Select/Develop Tool to conduct Data Inventory
• Identify/Assemble Team
• Conduct Data Inventory
• Identify areas for process improvement
– New Data Elements
– Retired Data Elements
– Modified Data Elements
• Develop action plan
– Include process for approval, repository and oversight
• Conduct annual evaluation of Data Inventory for updates
– New Data Elements
– Retired Data Elements
– Modified Data Elements
Data Inventory Example
Data Element
Fall Events
Data Source
Event
Reporting
System
Frequency
Responsible
Party
Reporting
Path
Per
occurrence
Falls
Committee
-Unit Staff
Meetings
-Dept.
Meetings
- PI/PS
Committee
- Board
- NDNQI
- HEN
Impact Areas
All clinical
& admin
areas
Regulatory
Guide
-PSO
-TJC
-CMS
-NDNQI
-HEN
Mitigating Risk & Injury
using Data & Deep-dive Analysis
2012 AHRQ Patient Safety Culture Survey 12 Composite-Level Results
http://www.ahrq.gov/professionals/quality-patient-safety/patientsafetyculture/index.html
“Learn to Report & Report to Learn!”
Age of Patient
300
242
250
200
185
181
150
112
100
50
8
0
<18 years
Adult (18-64 years)
Mature Adult (65-74 years) Older Adult (75-84 years)
Aged Adult (85+ years)
Age of Patient
300
66% ≥ 65 years & older
242
250
200
185
181
150
112
100
50
8
0
<18 years
Adult (18-64 years)
Mature Adult (65-74 years) Older Adult (75-84 years)
Aged Adult (85+ years)
# of Patients with Repeat Falls
657 Unique Patients = 728 Falls
700
600
581pt = 581 Falls
500
20% = Multiple Falls Events
400
300
63% multiple fall events occurred during same episode of care
(Injury = 1 Major, 1 Moderate, 6 Minor, 139 None)
200
100
53pt = 106 Falls
11pt = 33 Falls
2pt = 8 Falls
3 Falls
4 Falls
0
1 Fall
2 Falls
# of Patients with Repeat Falls
700
79% = Aggregate Single Fall Events
600
500
581
400
21% = Aggregate Multiple Fall Events
520
300
200
52pt
100
44pt
11pt
10pt
2pt
4pt
0
0
1 Fall
2 Falls
3 Falls
4 Falls
1pt
5 Falls
0
1pt
6 Falls
Fall Events by Time of Day
25
11pm - 12am
14
10pm - 11pm
20
9pm - 10pm
23
8pm - 9pm
28
7pm - 8pm
6pm - 7pm
34
5pm - 6pm
37
31
4pm - 5pm
42
3pm - 4pm
34
2pm - 3pm
1pm - 2pm
35
36
12pm - 1pm
11am - 12pm
39
31
10am - 11am
36
9am - 10am
31
8am - 9am
19
7am - 8am
53
6am - 7am
23
5am - 6am
25
4am - 5am
31
3am - 4am
26
2am - 3am
31
1am - 2am
23
12am - 1am
0
10
20
30
40
50
60
Activity Prior to Fall Event
200
180
160
180 TOP 5 Activity Categories
145
140
120
100
80
60
40
20
0
116
88
70
45
30
22
14
8
4
6
Interventions Used to Prevent Falls
500
450
400
350
TOP 5 INTERVENTIONS
458
446
434
389
365
313
300
250
200
150
100
50
0
225
185
178
151
80
77
26
21
5
12
Fall Patients on Anticoagulants
450
420
400
350
35% On Anticoagulants
300
250
229
200
150
100
50
0
Yes
No
Scorecards
http://www.klipfolio.com/resources/articles/what-are-dashboards-scorecards
Dashboards
http://www.klipfolio.com/resources/articles/what-are-dashboards-scorecards
Let’s have lunch!
Next Up:
Methodologies in Minimizing Risk & Injury
Methodologies in Minimizing
Risk and Injury
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Gap Analysis
Process Flow Charting
Cause & Effect Diagraming
Affinity Diagraming
Root Cause Analysis (RCA)
Failure Mode Effect Analysis (FMEA)
Gap Analysis
• Definition
– Gap analysis refers to a study where a healthcare organization
compares the present policy, procedure, SOP's, infrastructure with
defined laid down standards such as Evidence-based Practice
Standards, accreditation standards, regulatory standards, etc.
• Benefits
– Produces a written status of the current compliance of the
organization to the most recent internal/external guidelines and
standards of care.
– The written status, defined by organizational response, includes the
identification of necessary actions to be taken to become compliant
with internal/external guidelines and standards of care.
• Examples
– http://www.hret-hen.org/
– http://www.ismp.org/selfassessments/Hospital/2011/Default.asp
Institute of Safe Medication Practice Self-Assessment Tool
Steps to conduct a Gap Analysis
1. Assemble the Gap Analysis team, inclusive of both clinical and
administrative staff who are directly involved in the
system/process being assessed.
2. Define each item on the Gap Analysis tool to compare current
organizational practice to recommended practice.
3. Identify and discuss inconsistencies in practice and/or
perceptions related to each of the process steps.
4. Collect information on the extent to which the process step is
actually being carried out or in place, i.e. review of data
reports, direct observation, policies/procedures/protocols.
5. Record the final consensus as to the extent the safety practice
is in place.
6. Measure the overall compliance with the system/process
steps, by calculating percentage (%) compliance by dividing the
number of those items identified as compliant by the total
number of items.
7. Identify responsible party for follow up or action.
The target goal should be 100% compliant.
Gap Analysis Example
Institute of Healthcare Improvement (IHI) Appropriate Care Patient Safety Assessment Tool
Process Flow Chart Symbols
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•
Start/End
Process Step
Decision
Connector
Inspection
Wait
Transportation (Movement)
Document
Flowchart Exercise:
Medication Administration – Sliding Scale Insulin
1. Define the process
2. Define the process
boundaries
3. Identify steps, activities,
decisions
4. Assign flowchart symbols
5. Are steps in sequence?
6. Put steps in sequence
7. Review and title flowchart
Start
Step
Step
Step
Decision
YES
Step
Document
Stop
NO
Step
Interpreting the Process Flowchart
• Examine each process step
• Bottlenecks?
• Weak Links?
• Poorly defined steps?
• Cost-added-only steps?
• Examine each decision symbol
• Can this step be eliminated?
• Examine each rework loop
• Can it be shortened or eliminated?
• Examine each activity step
• Does the step add value for the end-user?
http://www.wisc-online.com/objects/ViewObject.aspx?ID=MFQ102 James Bork/author
Assess your Knowledge of Process
Flow Charting
• Brainstorming with people involved in the process is a
good way to identify the steps, activities, and decisions in a
process. (True or False)
• A point in a process at which a yes/no question is being
asked or a decision is required is illustrated with a box or
rectangle. (True or False)
• It is best to flowchart a process as it was designed to be
done rather than as it is actually being carried out. (True
or False)
• When examining your flowchart, rework loops are a good
place to find opportunities for improved efficiency. (True
or False)
Affinity Diagram
Brainstorming
Organizing Ideas
Cause & Effect Diagram (Fishbone)
Staffing
Environment
Equipment
Supplies
Patient
Event
Competency
Training
Rules
Policies
Procedures
Protocols
Documentation
Communication
Anatomy of an Error
Swiss Cheese Model of System Failure
Error Causation: Medication Error
Ishikawa Diagram (Fishbone)
Benefits of RCA and FMEA
• Improve the Efficiency and Effectiveness of
Operations
• Investigating and addressing root causes
• Enhance Organizational Performance
• Increasing involvement and engagement
• Enhancing Culture of Safety
• Improve Safety and Quality
• Narrowing and eliminating gaps
• Improve Financial Performance
• Streamlining processes, eliminating waste
• Reducing risk of liability
• Enhance Team Approach
• Empowering staff
• Enhancing Critical Thinking Skills
Shared Characteristics
• Oversight and support of leadership
• Goal to reduce the possibility of future
events and harm
• Identification of conditions that lead to
harm
• Non-statistical methods of analysis
• Team activities that require people, time,
materials and support
Pitfalls of RCA and FMEA
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Conducting RCA/FMEA just to fulfill a requirement
Choosing a process that is too complex
Inadequate team member representation
Lack of leadership support
Wasting time on long debates
Too little time for process redesign and
implementation
Failing to assign responsibility
Failing to develop measurement guidelines
Failing to track progress and follow up
Failing to establish timelines
Organization Approach to
Successful RCA & FMEA Activities
• Leadership Support
• Importance of the activities
• Provision of resources
• Response to findings
• Ongoing Commitment to Safety
• Identification of potential risk
• Improvement of processes
• Sustain and strategic performance improvement
• Establish/Maintain Culture of Safety
• Utilization of tools to direct improvement efforts
• Effective information management
• Obtaining, managing and utilizing information to improvement
systems/processes
• Well-trained and qualified personnel
• RCA/FMEA teams are trained in use of techniques/tools and
knowledgeable about topics
Root Cause Analysis – Let’s get
started!
• “Root Cause Analysis is a process for
identifying the basic or causal factor(s)
underlying variation in performance,
including the occurrence or possible
occurrence of a sentinel event…”
• “Root Cause: a fundamental reason for
the failure or inefficiency of a process.”
• “Sentinel Event …..
Definitions
• Sentinel Event (SE)
• “An unexpected occurrence involving death
or serious physical or psychological injury or
the risk thereof.
• “or the risk thereof” includes any process
variation for which a recurrence would
carry a significant chance of a serious
adverse outcome
• SE signals the need for immediate
investigation and response
• SEs and Errors are not synonymous! Not all
SEs are due to error and not all errors result
in a SE
Appropriate Use of RCA
• When to conduct a RCA
• Retrospective investigation of
processes/systems failures that resulted
in an adverse or sentinel event
• Retrospective investigation of a near
miss event that had the potential to
result in an adverse or sentinel event
• Retrospective investigation of a pattern
of incidents or near misses to
understand variation in systematically
collected data. (Aggregate RCA)
Conducting a Root Cause Analysis
• Designing and Implementing Early Response
Strategies
• Chartering and Assembling the Team
• Team Orientation
• Defining the Problem and Contributing Process
Factors
• Measure – Collect and Assess Data/Information on
Proximate and Underlying Causes
• Designing and Implementing Action Plans for
Immediate and Long Term Improvement
• Developing Measures of Effectiveness
• Evaluating/Modifying Implementation of
Improvement Efforts
• Communicating Results
Early Response Strategies
•
•
•
•
•
•
•
•
Immediate Response to Sentinel Events
Appropriate Care
Communication
Risk Containment
Preservation of Evidence
Documentation of Event
Disclosure
Interviewing Involved Staff
Immediate
Caregiver
Supervisor
Service
Director
Incident
Response Team
STABILIZE &
Treat the Patient
if required
NOTIFY
Supervisor
& Provider
Call for Medical
Support if
Required
ARRIVE on
site
immediately
ARRIVE on
site as
needed
ARRIVE on
site within 2
hours
Assure
patient
has
needed
care
CONFIRM
patient
status
COLLECT
names/contact
info of
staff/witnesses
SECURE
Scene +
Notify
Security, if
needed
Validate
scene is
secure
NOTIFY
Incident
Response
Team
COLLECT
preliminary
info,
Forensic
evidence,
photos, etc..
Prepare to
Document Facts
of Event
Assess &
provide
initial
support
Assure
staff has
needed
support
COORDINATE
Disclosure to
patient/family
Continue to
care for
patient and
await
direction
Notify
Service
Director,
Coroner if
required
Remain at
scene
Notify Senior
Admin/
Designee
CONTACT
CEO/Board
as
appropriate
ARRANGE
or
CONDUCT
Interviews
Management of Serious Clinical Events: Early Response Strategies
CONFIRM
Documentation
Communication
• Confidential Communication Loop
• Patients and families affected
• Appropriate staff, Risk/Quality/Patient
Safety staff identified by organizational
Sentinel Event Policy
• Colleagues who could provide clarification,
expertise and support
• Organization’s and provider’s liability
experts
• Others who could provide emotional
support or problem-solving assistance
Risk Containment
• The act of containing the risk from reoccurring
• Examples of immediate risk containment
actions:
•
•
•
•
Separate storage for look-a-like drugs
Separate storage insulin and TB syringes
Validating all medical gas connections
Validating all infusion pumps are correctly
calibrated
• Communicating information and validating
knowledge of correct practice to “need to
know” staff
Preservation of Evidence
• Evidence is critical in understanding what
happened
• Process is defined by organizational policy
• Included as part of Event Reporting Orientation
& Training
• Examples of evidence preservation include:
•
•
•
•
•
•
•
Biological specimens
Medications/syringes/vials
Supplies and supply packaging
Blood bags/Blood administration tubing
Dressings
Equipment/equipment supplies/electrical cording
Photos, as indicated
• Bagged and sequestered
Documenting Adverse Events in
the Medical Record
• The most involved and knowledgeable
member(s) of the care team are assigned
to record factual statements of the event
and any follow-up interventions and
patient outcomes.
• Do NOT document any information that is
unrelated to the care of the patient.
Example: “Incident Report completed” or
“Risk Management/Legal Office notified”
Disclosure
• When to Disclose a Medical Error
• Has a perceptible effect on the patient that
was not discussed in advance as a known
risk
• Necessitates a change in the patient’s care
• Potentially poses an important risk to the
patient’s future health
• Involves providing a treatment or procedure
without the patient’s consent
Interviewing Involved Staff
• Create a safe environment
• Be non-judgmental
• Staff are already anxious and easily defensive,
respect is critical
• Assume staff had reasons for their actions
• Avoid confrontation and challenging questions
• Asking the right questions in the right way
• Examples of open questions
• “Tell me what happened?”
• “What do you think led up to the event?”
• “Explain how these assessments/inventions are
done on your unit?”
• Clarify the information when needed
• “Tell me more about the handoff process.”
• “Help me understand what was happening when you
were giving medications?
Senior Leadership
Chief of
Staff
Risk/Quality/Patient Safety
ASSESS
potential
liability
MEET with
Sr. Ldship
WITHIN 1
working
day
MEET with COS,
CMD,
Risk/Quality/
Patient
Safety/Service
Director
Support
Physician
needs
Meet with
Incident
Response
Team
Update
Sr. Ldshp
Establish
direction and
assign
responsibility,
as indicated
Assess/Needed
action (as
indicated) for
any physician
performance
issues
Charter RCA
Team
Communicate
updates with
Sr. Ldshp as
indicated
WITHIN 7
working
days.
WITHIN 21
working
days.
1st RCA
RCA Risk
Reduction
Strategies
present to Sr.
Ldsp for sign
off
PRESENT to
PS/QI/RM
Cmte, 1st
available
meeting date
WITHIN 5
working days of
Sr. Ldsp Sign Off
– Communicate
to Staff
Management of Serious Clinical Events: Post Event
RCA Close
Out
Meeting
RCA Close
Out
Meeting
WITHIN 6 months
– Follow up to
assess status of
recommendations
Organize a Team
•
Select team members (Facilitator & Leader)
•
•
Trained in RCA
Subject Matter Experts
•
•
•
•
•
•
•
•
•
•
Physician Champion
Analytic Skills
Performance Improvement knowledge
Patient Safety knowledge
Event-type expert (Falls, Pharmacy, etc..)
Change Management Expert
Representative(s) from relevant service/discipline
Any level of staff closest to issue and has process
knowledge
Those involved in event (case-by-case decision)
Decision-making authority
Team Meeting Preparation
•
Team Member Information/Resources
•
•
•
Define the Problem
•
•
Timeline sequencing the event & RCA forms
• Medical Record, Staff Interviews, logs, check
sheets, etc..
Policies, Procedures, Protocols, SoC/SoP
“A well-defined problem statement describes what
is wrong and focuses on the outcome, not why the
outcome occurred.”
Brainstorming the problem
•
Define preliminary work plan
• Understand the scope of the plan (Charter)
• Key Steps
Team Responsibilities
•
Identify Contributing Process Factors
•
Flowcharting
•
•
•
Brainstorming
•
•
•
•
•
“What are the steps in the process?”
“What actually happened?”
5 Whys
Identify processes
Supplement the list of process steps
Affinity Diagram (organizing ideas)
Fishbone Diagrams
• “Which steps and linkages were involved in
or contributed to the event?”
Flow Charting the Process
Start the Process
Action
Action
Action of
Omission or
Commission
Action
Decision
Action
Action
Stop the Process
“5 Whys” Tool
Problem Statement: (One sentence description of event)
Why?
Why?
Why?
Why?
Why?
ROOT CAUSE(S): If removed, would this have been prevented?
Team Responsibilities
•
•
Identify Other Contributing Factors
• Procedure-related Failures
• Training-related Failures
• Equipment-related Failures
Measure – Collect and Assess Data on Proximate
and Underlying Causes
• Goal-directed activities/results of performance
•
•
Assess Data on Proximate and Underlying Causes
Prune and Confirm the List of Root Causes
• “Is it likely that similar conditions will recur if
the cause is corrected or eliminated?”
• If answer to each is NO = Root Cause
Team Responsibilities
•
Explore and Identify Risk Reduction
Strategies relevant to Root Causes
•
•
•
•
•
•
Past RCA Action Plans (Effectiveness)
Literature Reviews
Evidence-Based Practice Guidelines
• Discipline-Specific (AORN)
• Diagnosis-Specific (AMI, Pneumonia)
• Procedure-Specific (Medication Safety)
• Error Prevention Strategies (Falls, Alarm
Fatigue, Hourly Rounding, CUSP, TeamSTEPPS,
Time Outs, Read-Back, etc..)
Staff Recommendations
Patient/Family Recommendations
Others as identified
Definition: Action Plan
• “Action Plan: the product of the root cause
analysis that identifies the strategies that an
organization intends to implement to reduce
the risk of similar events occurring in the
future.”
• Action Plan identifies responsibility for:
• Implementation
• Oversight/Responsibility
• Pilot testing, as appropriate,
• Time lines
• Strategies for measuring the effectiveness
National Center for Patient
Safety
STRONGER ACTIONS
• Architectural/physical plant changes
Intervention Hierarchy
• New devices with usability testing before purchasing
(Focused on system change, not reliant •
on individual memory/vigilance)
•
•
•
Engineering control or interlock (forcing functions)
Simplify the process and remove unnecessary steps
Standardize equipment on process or caremaps
Tangible involvement and action by leadership in support of
patient safety
INTERMEDIATE ACTIONS
•
•
•
•
•
•
•
•
Redundancy
Increase in staffing/decrease in workload
Software enhancements/modifications
Eliminate/reduce distractions
Checklist/cognitive aid
Eliminate look and sound-alikes
Readback
Enhanced documentation/communication
Weaker Actions
•
•
•
•
•
Double checks
Warning labels
New procedure/memorandum/policy
Training
Additional study/analysis
(Reliant on memory/vigilance)
Team Responsibilities
•
Develop the Action Plan targeting Risk Points
or Common Causes
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Training/Education
Competence (lapses/low volume-high risk task)
Supervision
Staffing (workflow & workload)
Communication
Distraction due to environmental issues
Information availability
Storage and access
Labeling
Nomenclature
Dosage calculation
Equipment
Abbreviations
Handwriting
Tips related to Mistake-Proofing
for Human Factors
• Design strategies to prevent errors
• Automation
• As appropriate
• Incorporate “forcing functions”
• Standardization
• Reduce need to rely on memory
• Develop checklists
• Modeled by policy/procedure/guidelines
• Incorporate into medical record documentation, as
appropriate
• Reduce the number of process steps
• Handoffs
• Patient Movements
• Ensure redundancy (double checks)
• High risk processes
Team Responsibilities – Close Out
•
Finalize the RCA Documentation
•
•
Complete the organizational RCA Forms to include:
• Event description
• Timeline of the event
• Results of data measurement
• Flowcharts, Fishbone, and other graphics
• Final root causes
• Action Plan with assigned responsibility/target
dates
• Results of any pilot testing
• Supporting documents/references used
• Add to RCA system tracking mechanism
Present RCA to Senior Leadership for Approval
•
•
Present findings
Provide needed clarification/justification
RCA: Let’s Practice
Case Study:
82 year old female admitted to the Outpatient
Surgical Unit to undergo a Total Knee Replacement .
The surgical procedure was uneventful and she was
transferred to PACU for her recovery period of 1 hour
and was transferred to the Inpatient Orthopedic
Unit.
3 hours after coming to the Orthopedic Unit, she was
found to be in respiratory arrest, a code was called,
she was resuscitated and transferred to the ICU for
post-code management.
RCA: Let’s Practice
What information does the Team need to focus on?
RCA: Let’s Practice
Case Study:
34 year old male was admitted to the Mental Health Unit
for Manic-Depressive Disorder.
Day 3 of his inpatient stay, he failed to report to the
medication administration area for his afternoon meds.
No communication of his failure to receive medications
was followed through. Within the hour, a transport
assistance found a male, dressed in mental health
inpatient attire, wandering around the receiving dock and
called Security. Security responded to the area and called
the 2 locked mental health units, with a response of “no
patients are missing”. 45 minutes later 1 unit called
Security back and responded that the patient belonged on
their unit.
RCA: Let’s Practice
What information does the Team need to focus on?
Transitioning to Failure Mode
Effects Analysis (FMEA)
• Everything we learned and discussed
for RCA applies to the FMEA process
BUT in the “Proactive” mode!!!
• Team mix and responsibilities
• Tools and techniques
• So what’s different?
Definition
• “Failure Mode and Effects Analysis is a
team-based, systematic proactive, and
reason-based technique that is used to
prevent process and product problem
before they occur. It provides a look not
only at what problems could occur but
also at how severe the effects of the
problems could be.
• …assumes that no matter how
knowledgeable or careful people are, errors
will occur in some situation and may even
be likely to occur.”
Definitions
• “Failure: When a system or part of a
system performs in a way that is not
intended or desirable.”
• “Mode: the manner in which something
can fail.”
• “Effects: The results or consequences of
a failure mode.”
• “Analysis: The detailed examination of
the elements or structure of a process.”
Steps to Conduct Failure Mode
Effects Analysis (FMEA)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Select a high-risk process
Assemble a team
Diagram the process
Brainstorm potential failure modes and
determine effects
Prioritize failure modes
Identify root causes of failure modes
Redesign the process/sub-process
Analyze and test the new process
Implement and monitor the redesigned
process
Appropriate Use of FMEA
• Risk Areas to Consider
• High Risk provision of care
• Restraint Management
• Poorly performing processes/systems
• Low volume – low risk but repetitive in errors
• Frequent Near Misses
• Low volume – High risk
• New services or programs
• Electronic Medical Record Implementation
• Bar Code Medication Administration
• New CV unit
• New patient population
• New buildings or expansions
• Aligns with Strategic/Operational Plans
FMEA Selection Process
• Sources for Identifying High Risk Processes to
Analyze
•
•
•
•
•
•
•
•
•
Organizational PI data
Patient/Family Feedback (Satisfaction Survey)
Staff Feedback (Safety Culture Survey)
Occurrence Reporting System
Aggregate RCA Findings
Professional Associations
Mandatory Reporting Topics
Liability Insurance Companies
Sentinel Event Alerts and Statistics (Joint
Commission)
Flow Charting for the RCA Process
Start the Process
Action
Action
Action of
Omission or
Commission
Action
Decision
Action
Action
Stop the Process
Laboratory Test Ordering Process
Flow Charting for the FMEA
Process
PROCESS COMPONENTS
1. Physician
writes order
1a. Unable to read orders
1b. Previous orders not
discontinued
1c. Duplication of orders
1d. Write order for
wrong patient
2. Physician
returns chart
to desk
2a. Chart not collected
2b. Chart not returned
FAILURE MODES
3. UC
Enters
order into
system
3a. Order not entered
3b. Wrong lab test entered
3c. Enter order for wrong day
3d. Enter order for wrong patient
3e. Order not customized
3f. Different UC enter orders
differently
3g. Multitasking and
distractions
Considering Potential Effects of
Failure Modes & Prioritizing
Possible Failure Potential Effects
Modes of
3.
PROBABILITY
Medication
Administration
Potential Effects
SEVERITY
Priority
Score
3a. Wrong Drug
Low likelihood
(1 in 5,000)
SCORE = 2
Injury with permanent loss of
function; death SCORE = 5
3b. Wrong Dosage
Moderate likelihood
(1 in 200)
SCORE = 3
No injury but increased length 2X3=6
of stay to monitor effects
SCORE = 2
3c. Wrong Time
High likelihood
(1 in 100)
SCORE = 4
Injury with no permanent loss
of function
SCORE = 3
4X3=12
3d. Wrong route
Low likelihood
(1 in 5,000)
SCORE = 2
Injury with permanent loss of
function; death
SCORE = 2
2X2=4
2X5=10
Communication and Tracking
Status of RCA & FMEA
• Quality/Risk/Patient Safety staff
• Communication
• Results to appropriate
staff/groups/committees as defined
in policy & procedures
• Tracking
• Establish an effective tracking system
for RCA & FMEA follow up
• Status updates at pre-determined
timeframes
Let’s take a break!
Next Up:
Redesigning for Patient Safety
Redesigning for Patient Safety
• Application of the science, measurement
and methodologies to redesign patient
safety processes and systems
– Evidence-Based Practice guidelines, tools and
resources
– Critical elements and skills necessary for
oversight and management of patient safety
improvement activities for system-wide
implementation
“Isn’t it nice when things just work?”
http://www.youtube.com/watch?v=_ve4M4UsJQo
Redesigning:
Where do we start?
Gears & More Gears!!!
EXERCISE
Who is accountable and responsible for Patient Safety?
Governing
Board
Leadership
Organizational
Chart
(Job Functions, Line Authority
& Policy/Procedure in Day-toDay Operations and
Provision of Care)
PATIENT
SAFETY
Committee
Structure
(Planning, Designing,
Implementing &
Evaluating Initiatives)
Organizational Infrastructure
Mission/Vision/Values
Operationalizing Patient Safety Initiatives
GB
Leadership
PATIENT
SAFETY
Organizational Chart
Committee
Structure
Organizational Infrastructure
Mission/Vision/Values
Culture of
Safety
Leadership
Commitment
AHRQ Safety
Culture Survey
Transparency
Incident, Near
Miss & Unsafe
Condition
Reporting
Risk
Assessment
Process
Improvement
EBP
Initiatives
Measurement/
Reporting
Mistake Proofing
CUSP/
TeamSTEPPS
Data Inventory
FMEA
NCPS Patient Safety
Assessment
Hourly Rounding
High Reliability
Patient/Family
Advisory Councils
Disclosure
Staff Education
Awareness
Reward &
Recognition
RCAs & Lessons
Learned
Story Telling
ISMP
Medication
Safety SelfAssessment
Other
Internal/External
Regulatory
Requirements
Just Culture
Falls, Pain,
Restraints, etc.
Technology
Surgical Never
Events
Others as
Indicated
Gap Analysis vs.
Requirements
/Findings
Add/Delete/
Modify/Assign/
Report
Sustain
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
Strategies for Implementation
• Assessment
– Establish/Identify the “Planning Team”
– Gather appropriate information for team
review/discussion
•
•
•
•
•
Policy/Procedures
Current literature/research
Current/Historical data results & analysis
Survey results
Evidence-based practice models
– Identify the need
• Gap Analysis
– Prioritize the need
• Compare the potential risks and benefits
• Compare the current competing initiative/activity priorities
– Identify potential impacting factors
• Supportive
• Barriers
“ADAPTS Implementation Science Model”
Strategies for Implementation
• Deliverables
– Gain executive support of initiative implementation
– Identify Champion Facilitator/Team Leader or
Committee Chair
– Identify the “Implementation Team” or Committee
Members
– Identify the resources necessary to carry out
implementation
• Activate
– Communicate goal, objectives, expected outcomes and
process parameters to “Implementation Team”
• Provide Gap Analysis Results to “Implementation Team”
– “Implementation Team” utilizes Patient Safety Science
methodologies to determine implementation plan for
presentation to the “Planning Team”
“ADAPTS Implementation Science Model”
Strategies for Implementation
• Pre-training
– Champion presents groundwork to leadership and
relevant department managers
• Needed changes/additions/deletions to processes &
process guidelines (Clinical & Administrative)
– Initiate organization-wide awareness campaign
– Makes final modifications to implementation plan
• Training
– Appropriate staff are educated via appropriate
teaching techniques (i.e. briefing, in-services, handson training, etc.)
– Completed training is documented and maintained
“ADAPTS Implementation Science Model”
Strategies for Implementation
• Sustainability
– “Implementation Team” or “designated entity”
takes charge of sustaining implementation
• Serve as “Subject Matter Experts” resource for
organization
• Oversight of process/process guidelines
• Define measurement process
• Define the reporting structure and process
• Responsible for annual or designated timeframe
evaluation
• Make recommendations and coordinate the
implementations of modifications as needed
“ADAPTS Implementation Science Model”
Setting Performance Standards And
Expectations For Patient Safety
Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices (AHRQ Evidence
Report No. 211)
1. Preoperative checklists and anesthesia checklists
12. Use of Pharmacist to reduce ADEs (MATCH)
2. Tools for Reducing Central Line-Associated Bloodstream
Infections
13. Patient preferences for life-sustaining treatment
3. On the CUSP: Stop CAUTI
4. Bundles to prevent ventilator-associated pneumonia
14. Use of informed consent to improve patients'
understanding
15. TeamSTEPPS®
5. Hand hygiene.
16. Medication Reconciliation (MATCH)
6. "Do Not Use" list for hazardous abbreviations
17. Practices to reduce radiation exposure
7. Multicomponent interventions to reduce pressure ulcers
18. Use of surgical outcome measurements
8. Barrier precautions to prevent healthcare-associated
infections
19. Rapid response systems
9. Use of real-time ultrasound for central line placement
20. Utilization of complementary methods for detecting
adverse events/medical errors to monitor for patient safety
problems
10. Interventions to improve prophylaxis for venous
thromboembolisms
21. Computerized provider order entry
11. Preventing Falls in Hospitals
22. Use of simulation exercises in patient safety efforts
http://www.ahrq.gov/research/findings/evidence-based-reports/makinghcsafer.html
AHRQ Guides
• http://www.ahrq.gov/research/findings/evide
nce-based-reports/makinghcsafer.html#guides
IHI Patient Safety Leadership
WalkRounds™
• Definition
– A tool to connect senior leaders with people working on
the front line as a way both to educate senior leadership
about safety issues and to signal to front-line workers the
senior leaders’ commitment to creating a culture of
safety.
• Benefits
– Demonstrate commitment to safety.
– Fuel culture for change pertaining to patient safety.
– Provide opportunities for senior executives to learn
about patient safety.
– Identify opportunities for improving safety.
– Establish lines of communication about patient safety
among employees, executives, managers, and
employees.
– Establish a plan for the rapid testing of safety-based
improvements.
http://www.ihi.org/knowledge/Pages/Tools/PatientSafetyLeadershipWalkRounds.aspx
TeamSTEPPS® (Team Strategies and Tools to
Enhance Performance and Patient Safety®)
• Teaches healthcare professionals skills and competency to
integrate teamwork principles into daily practice
throughout the organization and include:
 Skills:
• Leadership
• Mutual Support
• Situation Monitoring
• Communication
 Competencies:
• Performance
• Attitudes
• Shared Mental Model
http://teamstepps.ahrq.gov/
Hourly Rounding
• Definition:
– Purposeful Hourly Rounding is…an evidence-based practice to:
• Meet patient needs
• Improve safety outcomes
• Increase patient comfort
• Improve the nursing care delivery experience
• Reduce # of call lights
• Reduce distances walked
• Benefits
– Designed to promote high quality patient care
• Increases patient satisfaction by average of 12 raw points
– Provides health care that is safe
• Reduces falls up to 50%
• Reduces pressure ulcers up to 16%
– Increases efficiency for staff
• Anticipates reasons why the call lights ring
• Reduces call lights up to 38%
• Saves nurses from 150 – 300 hours per month
http://www.mc.vanderbilt.edu/root/pdfs/nursing/hourly_rounding_supplement-studer_group.pdf
Partnership for Patients (HEN Project)
• Goals:
• Reduce Preventable Complications by 40% to make care
safer
• Reduce Readmissions by 20% to improve care transitions
• Areas of Focus:
•
•
•
•
•
•
•
•
•
•
Adverse Drug Events
Catheter-Associated Urinary Tract Infections
Injuries from Falls and Immobility
Obstetrical Adverse Events
Pressure Ulcers
Surgical Site Infections
Venous Thromboembolism
Ventilator-Associated Pneumonia
Readmissions
Elective Delivery
http://partnershipforpatients.cms.gov/about-the-partnership/patient-and-family-engagement/the-patient-and-family-engagement.html
Patient Safety Competencies
• Patient Safety Competencies address:
• Communication
• Team participation
• Risk Recognition
• Recognition & Reporting of Errors
• Accountability & Responsibility
• Understanding Culture of Safety
• Concepts
• Attitudes
• Skills
• Patient Centered Care
Patient Safety Certification
• Certified Professional in Patient Safety (CPPS)
– Establishes core standards for the field of
patient safety, benchmarks requirements
necessary for healthcare professionals, and sets
an expected proficiency level
– Gives those working in patient safety a means
to demonstrate their proficiency and skill in the
discipline.
– Provides a way for employers to validate a
potential candidate’s patient safety knowledge
and skill base, critical competencies for today’s
healthcare environment
http://cbpps.org
ARE YOU READY?
Q&A