Transcript Making A Title Slide - Northwestern Memorial Hospital

Improving Culture and Learning from Errors with a
Nursing Morbidity and Mortality Program
Prepared For
2009 ANCC National Magnet Conference
October 1, 2009
By
Jane Menendez, RN
Ann Schramm, RN, MSN
This Discussion will Cover . . .
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The Goal: A Culture of Safety
Morbidity & Mortality Programs
– How to
– Design
– Implement
– Use the findings
– Evaluate
Northwestern Memorial Hospital
•
Mission: “Academic Medical Center
Where the Patient Comes First”
•
Strategic Goals: Best Patient Experience, Best People,
Exceptional Financial Performance
•
Primary Teaching Affiliate of
Northwestern University’s
Feinberg School of Medicine
(>500 Residents / 125 Fellows)
• RNs 2223
Page 3
State of the Art Facilities
• $580 Million Redevelopment Project
• 3 Million square feet covering one city block
• High Tech – “Most Wired”
• Level I trauma networks and
Level III neonatal intensive care unit
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9000+ deliveries
Total Beds:
Total Admissions:
Total Outpatient Visits:
Total Outpatient Clinics:
ED Visits:
Average Daily Census:
897
43,312
438,979
13
73,881
596
Pursuing a Culture of Safety
What does a culture of safety look like?
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Organizational commitment to create and support safe
systems
Environment in which individuals feel free to
– identify errors
– openly question the safety of existing systems, and
– constructively analyze problems
Errors are used for learning and for improving
Hierarchies are flattened
Transparency at all levels is encouraged
Dana-Farber Cancer Institute Principles of a Fair and Just
Culture, Dana-Farber Cancer Institute, accessed at www.danafarber.org/abo/news/tools/justculture.asp.
Who creates and exhibits a culture of safety?
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The environment for the culture is created by
organizational leadership, which provides the
atmosphere and opportunities for learning from
error
The culture is adopted by staff members at all
levels of the organization, who respond to and
benefit from the created environment
Wilkins BA. (2004). A brief summary of concepts from nuclear energy’s
work to develop a safety culture. Inova Health System.
High Reliability Organizations
• Preoccupation with failure
• Reluctance to simplify interpretations
• Sensitivity to operations
• Commitment to resilience
• Deference to expertise
Weick KE & Sutcliffe KM (2001). Managing the Unexpected: Assuring
High Performance in an Age of Complexity. San Francisco: Jossey-Bass.
How Do You Know
Whether You Have a Culture of Safety?
• Incident reporting
• Interdisciplinary collaboration
• Walk Rounds
• Collegial rapid improvement projects
• Metrics such as AHRQ Hospital Survey on Patient
Safety Culture (HSOPSC)
National Challenges in Culture of Safety
AHRQ Hospital Survey on Patient Safety Culture (HSOPSC)
National Data: 382 hospitals and 108,621 hospital staff respondents
• Highest scores for Teamwork Within Unit
• Lowest scores for Nonpunitive Response to Error: “the lowest average
percent positive response (43 percent), indicating this is an area with
potential for improvement for most hospitals….”
• “The survey item with the lowest average percent positive response (35
percent) was: "Staff worry that mistakes they make are kept in their
personnel file" (an average of only 35 percent strongly disagreed or
disagreed with this item). “
Hospital Survey on Patient Safety Culture: 2007 Comparative Database
Report http://www.ahrq.gov/qual/hospsurveydb/hospdbch5.htm
How can we promote and support a culture of safety?
For example . . .
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Create structure for the systematic review of safety concerns
Establish care delivery practices that encourage teamwork
and collegial relationships among members of different
disciplines
Institute human resource policies that support a non-punitive
culture
Create vehicles for sharing and learning from errors
Patient Safety Morbidity & Mortality
Conference
Patient Safety M&M
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Created in 2003 to
– Openly identify and examine errors that occur in our
hospital
– Perform a retrospective analysis (root cause
analysis) with an interdisciplinary group
– Bring members of all disciplines together to share
information and problem-solving efforts
– Bring lessons learned and solutions back to M&M
participants
– Encourage further event reporting
Introducing the Idea and
Initiating the Conference
• Identify needed champions
• Ensure agreement on goals and process from other
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interested departments (e.g., Risk Management, Medicine,
Nursing, Pharmacy)
Establish organizational coverage for the M&Ms to maintain
their status as quality initiatives according to your state law
Identify needed resources (e.g., personnel for planning,
meeting space, time allotment for staff to attend/complete)
Patient Safety M&Ms:
Two Forums, Two Audiences
1. Interdisciplinary Patient Safety M&M
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Monthly live conference, beginning at noon for one hour in large conference
room that can seat up to 100 people
Notice of conference sent via email each month; interesting title
Lunch served to attendees
Nursing contact hours and ACCME credits for physicians offered for each
program
2. Nursing Patient Safety M&M
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Monthly online module completed by staff nurses
Case study directly related to nursing care
Interdisciplinary M&M Monthly Meeting
Interdisciplinary Patient Safety M&M
Program Organization
• Case study selected each month based on
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High priority recent events reported via incident reporting system
Other events related to ongoing clinical care / safety initiatives within the
organization (e.g., falls, medication reconciliation, handoffs)
On occasion, an event that occurred elsewhere, but could have happened at
our hospital
Panel is selected for each conference
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Panel members represent the disciplines involved in the actual event
– Typically physician, nurse, pharmacist
– May or may not have been actually involved in the event
Program Agenda
1. Closing the Loop on Previous M&M Findings
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Program begins with review of prior month’s
case with key findings and recommendations
from the M&M participants
2. Presentation of Case Study
The case is read; all audience members have a
hard copy for reference.
Program Agenda
3. Discussion, Root Cause Analysis (VA National Center for
Patient Safety model), and Plan for Improvement
VA Root Cause Framework
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Human Factors – Communication
Human Factors – Training
Human Factors – Fatigue/Scheduling
Environment/Equipment
Rules/Policies/Procedures
Effective Barriers/Controls to Protect Patient Safety
Example Interdisciplinary M&M
Sample M&M: Follow Up From Prior Month
Follow-up from September’s Case Studies: The Wrong Patient: Tests,
Medications, and Procedures Performed after Errors in Patient
Identification
Key Findings
Patients are frequently identified by care
providers without going through all of the
designated steps of the patient
identification process.
Recommendations
Patient identification must include:
 the use of two identifiers (e.g., patient
name and date of birth);
 confirmation of the patient’s first and
last name; and
 requesting the patient to state his/her
name (if able).
Patients are not always familiar with the
procedures they are scheduled to have and
may not have adequate knowledge to notify
providers if an incorrect procedure is
begun.
Attempt to better inform patients about the
procedures for which they are scheduled so that
they can more easily recognize whether the
preparation and procedure seem appropriate to
their clinical condition.
Empower patients to speak up if they think that
some aspect of their care or treatment seems
incorrect.
Perform a reassessment of HIPAA privacy
requirements to ensure that patient
identification practices do not introduce
unnecessary risk.
Interpretation of HIPAA requirements may
lead to error-prone patient identification
practices.
Sample M&M: Case Study for This Month
JW is a 42 year old female who presented to the Emergency Department on
7-10-07 with complaints of fever, chills, right flank pain, and pain on
urination. She was diagnosed with pyelonephritis, given a first dose of
intravenous ciprofloxacin in the Emergency Department at 0100 on 7-11,
and admitted for continuation of intravenous antibiotics. The order for
intravenous ciprofloxacin was placed as a “pharmacy to dose” order by
the admitting physician. The order was verified by the pharmacist, but a
dosed order was never entered. On the following day, 7-12, the patient
complained of increasing abdominal pain so a CT scan was completed
which revealed pyelonephritis. It was then discovered that the patient
had not received any intravenous ciprofloxacin since the first dose in the
Emergency Department. She received her second dose at 1800 that day
(7-12), 41 hours after her first dose. Her pain improved and her white
blood cell count began to fall. She was discharged home two days later.
Sample M&M: Case Study Discussion Guide
Triage Questions
• Were issues related to patient assessment a factor in this situation?
• Were issues related to staff training or staff competency a factor in
this event?
• Was equipment involved in this event in any way?
• Was a lack of information or misinterpretation a factor in this event?
• Was communication a factor in this event?
• Were appropriate rules/policies/procedures – or the lack thereof – a
factor in this event?
• Was the failure of a barrier designed to protect the patient, staff,
equipment, or environment a factor in this event?
Sample M&M: Case Study Discussion Guide
Focus on the following six categories
• Human Factors – Communication
• Human Factors – Training
• Human Factors – Fatigue/Scheduling
• Environment/Equipment
• Rules/Policies/Procedures
• Effective Barriers/Controls to Protect Patient Safety
Interdisciplinary M&M – Evaluation
Item
Score, average
(range 1-4, 4 is highest)
Overall assessment of program
3.82
As result of this program, I can describe
patient safety issues with a focus on
systems.
3.82
As a result of this program, I can describe
the process and components of a root
cause analysis.
3.62
As a result of the program, I can describe
strategies to improve patient safety.
3.75
Nursing Online M&M
Nursing M&M
Program Organization
• Case study selected each month based on
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Relevance to nursing practice
High priority recently reported events
Other events related to ongoing clinical care / safety initiatives within the
organization (e.g., medication administration)
On occasion, an event that occurred elsewhere, but could have happened at
our hospital
Online PowerPoint module created and posted online
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Nurses complete on their own
Managers have 85% completion goal for their staff
Example Nursing M&M Module
Picture is for illustration purpose only
NMH Patient Care Division
Patient Safety
Morbidity/Mortality Study Module
Patient Identification
November 2007
Exit
Upon Completion . . .
Participants will be able to:
• Identify the importance of performing a thorough and
accurate identification of any patient prior to providing any
patient care service.
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State the required components of the patient identification
process.
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Describe the unintended consequences of incorrect patient
identification.
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Explain methods for improving patient identification
procedures in their area of practice.
Accurate Patient Identification
The accurate identification of patients prior to the
provision of care – particularly the administration of
medications or the performance of any invasive
procedures – is an important role of professional
nurses in caring and advocating for their patients.
Picture is for illustration purpose only
Case Study #1
Ray Williams*, a 53 year old male, was
scheduled for a paracentesis in
Interventional Radiology (IR) on 09-04-07.
When the IR staff were ready to have the
patient transported, they selected the name
of another patient, Roy Williams, in the
teletracking system. The transporter
received the request for Roy Williams and
picked him up and transported him to IR for
the procedure.
Picture is for illustration purpose only
Roy Williams arrived in IR. In the holding area, a nurse discovered
that he was not the patient scheduled for the procedure and he was
returned to his room. Mr. Williams was angry and frightened by the
error.
*All names have been changed.
Case Review
1.
In case study #1, at what point(s) in the process
were there errors or lapses in patient
identification?
A. Requesting the patient in the transport teletracking system
B. Correct patient identification by the transporter in the
patient’s room
C. Identification of the patient by the transporter and the
patient’s nurse on the inpatient unit (handoff)
D. Identification of the patient by staff in the IR holding area
E. A and C
F. All of the above
Case Review
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Great Job!
– In this case, the incorrect identification of the patient began when the
IR staff selected the wrong patient name in the transport tracking
system. The error continued unrecognized because the transporter
and nurse on the inpatient unit had no communication prior to the
patient being picked up and taken to IR. Had the nurse been
contacted, she would have recognized that the patient being picked
up was not scheduled for an IR procedure on that day.
Case Review
• Incorrect. The correct answer is . . .
– A and C. In this case, the incorrect identification of the patient began
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when the IR staff selected the wrong patient name in the transport
tracking system. The error continued unrecognized because the
transporter and nurse on the inpatient unit had no communication
prior to the patient being picked up and taken to IR. Had the nurse
been contacted, she would have recognized that the patient being
picked up was not scheduled for an IR procedure on that day.
The transporter correctly identified the patient in his room and the
nurse in the IR holding area also correctly identified the patient,
leading to the discovery of the error.
Nursing M&M – Evaluation
• Online survey conducted to obtain nurses’
assessment of Nursing M&M
– Survey items taken from AHRQ HSOPSC survey
– 307 nurses responded, representing full range of
clinical areas – February – March 2008
– Responses compared to hospital-wide HSOPSC
culture survey responses for 716 nurses from May
2006
Nursing M&M Survey Results
Per Cent Positive Response
Nurse Responses
May 2006
100
90
80
90
Feb/March 2008
89
84
77
63
70
60
50
We are actively doing
things to improve
patient safety.
62
We discuss ways to Mistakes have led to
prevent errors from positive changes here.
happening.
Per Cent Positive Responses
Nursing M&M Survey Results
Nurse Responses - February/March 2008
78
76
74
72
70
68
66
64
62
The M&M programs
The M&M programs
help me to understand help me to identify
patient safety issues strategies to improve
with a focus on
patient safety on my
systems.
unit.
The M&M programs
are relevant to me in
my position.
Nursing Feedback on M&M Program
Many positive comments,
but some constructive criticism as well
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Nurses in Neonatal Intensive Care Unit and obstetrics
brought to our attention that
– “Scenarios are never geared towards maternal-fetal medicine.”
– “I feel like they never pertain to our unit.”
– “Would like to see some more neonatal specific, rather than adult
based.”
Nursing Feedback on M&M Program
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Some nurses preferred the original format, which involved
case presentation and discussion at a staff meeting
– “I think it was more beneficial when they were done by the
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manager.”
“I like the way we used to do M & Ms, which was discussing as a
group during staff meetings.”
Nursing Feedback on M&M
• Favorable responses overall
– “It is truly an eye opener to learn how mistakes are made and how
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NMH has come up with many safety tools and policies to prevent
them.”
“It is important to learn from actual cases that occur here at NMH and
the M&Ms mostly help as refreshers to how we should be practicing
and hopefully change people's bad habits.”
“I think that it is a great idea to learn from mistakes that did occur.
This teaches staff that it is human to err.”
Summary
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Patient Safety M&Ms have contributed to the creation of a
culture of safety at Northwestern Memorial Hospital and
have provided a valuable forum for the sharing of
experiences, ideas, and problem solving among clinicians of
multiple disciplines.
• We will continue to “reinvent” both programs based on
feedback from participants to maximize the programs’
usefulness for providers.
Questions / Discussion