Transcript Measurement and Monitoring of Safety

Moving to reliable care the new challenge for
paediatrics
Peter Lachman, Great Ormond Street
Hospital
Moving to reliable care –
the new challenge for
paediatrics
Peter Lachman
Foundations for safety
A safety policy
A feedback
loop to improve
safety
performance
A means of
measuring
safety
performance
Organisational
arrangements
to support
safety
A safety plan
The Measurement and Monitoring of Safety. Vincent C, Burnett S, Carthey J. THF. April 2013
Framework for safety
Past harm
Integration
and learning
Reliability
Safety
measurement
and
monitoring
Anticipation
and
preparedness
Sensitivity to
operations
The Measurement and Monitoring of Safety. Vincent C, Burnett S, Carthey J. THF. April 2013
Quality Care
Pediatrics: ADE Rates with Trigger Tool
Takata, Mason, Taketomo, Logsdon, Sharek. Pediatrics April 2008
960 Pediatric Inpatients;
11.1 ADEs per 100 admissions;
22x more ADEs than incident reports
74 Adverse Events per 100 admissions
56% of all Adverse Events “Preventable”
Adverse Events in the NICU setting are substantially higher than
previously described. Many events resulted in permanent harm, and
the majority were classified as preventable…
203 Adverse Events per 100 admissions
46% of all Adverse Events “Preventable”
“Adverse Events and Adverse Drug Events occur frequently in
the PICU setting…substantial risk in this vulnerable pediatric
population”
Understand processes of harm
Organisation &
Culture
Contributory
factors
work
place
culture
Environment
factors
Management
decisions &
organisational
processes
Staff factors
Latent
failures
Team factors
Task factors
Care delivery
problems
Unsafe Acts
Errors
Violations
Patient factors
Human
factors
Defences &
Barriers
Active
failures
Reference Reason and Vincent
Harm
What is reliability?
The child or young person should
receive, without delay, the care that is
needed and wanted the first time
every time no matter where he/she
lives.
and for medications
The child receives the correct
medication at the right dose
at the right time
every time
Drug that is needed
no overuse and
underuse on time
and stopped on time
Drug that is
tolerated
Drug that is
works
no overuse and
underuse
Strategies to Address Adverse Events
Regulations
Inspections
Practical approach-Target top offenders
Naming
Will not get you to high level of reliability
No sustainable change
“Every system is perfectly
designed to achieve exactly
the results it gets.”
• Paul Batalden after Deming
What is needed
‣ Effective distributive leadership
‣ Data feedback in real time
‣ Honour the work of the front line
‣ Engage physicians in all we do
‣ Involve patients and families from the
start
Large-System Transformation in Health Care:A Realist Review ALLAN BEST, TRISHA GREENHALGH, STEVEN LEWIS, JESSIE E. SAUL
Changing our role as professionals
‣Limitations on working harder
‣Eliminate professional autonomy
‣Become equivalent actors
‣System-level arbitration
‣Simplify rules and regulations
Five System Barriers to Achieving Ultrasafe Health Care. René Amalberti, Yves Auroy, Don
Berwick,; and Paul Barach, Ann Intern Med. 2005;142:756-764.
System Migration to Unsafe Practices
VERY UNSAFE SPACE
INDIVIDUAL BENEFITS
write mg and µg write mg and µg
in full depending in full some of the
who is on
time
= ‘IllegalIllegal’ `
space
Illegal
normal
Life Pressures
write mg and
µg in full
every time
Legal
Normal
Perceived
Vulnerability
Belief
Systems
ACCIDENT
PERFORMANCE
Reference Amalberti
Aim for High Reliability
• Regarding
small errors as
a symptom
that something
is wrong
Preoccupation
with failure
Sensitivity to
operations
• Paying
attention to
what’s
happening on
the front-line
Commitment
to resilience
• Encouraging
diversity in
experience,
perspective,
and opinion
Reluctance to
simplify
• Capabilities to
detect, contain,
and bounceback from
events that do
occur
• Pushing
decision
making down
to the front
line
Deference to
expertise
Attributes of High Reliability Organizations
 Preoccupation with failure
 Reluctance to simplify
interpretations
 Sensitivity to operations
 Commitment to resilience
 Deference to expertise
Weick, et al. Research in Organizational Behavior. 1999;21:81-123
Weick, Managing the Unexpected: Assuring High Performance in an Age of Complexity,
Jossey Bass 2001
Level 1 reliability
Intent, Vigilance and Hard Work
Can achieve up to 80-90% Reliability
 Common equipment, standard order sheets, multiple choice protocols, and
written policies/procedures
 Personal check lists
 Feedback of information on compliance
 Suggestions of working harder next time
 Awareness and training
from R Resar, IHI
Level 2 reliability
Human Factors and Reliability Science
Can achieve up to 95% reliability
 Decision aids and reminders built into the system
 Desired action the default (based on evidence)
 Built in redundant processes
 Use fixed current scheduling in design
 Take advantage of habits and patterns
 Elimination of variability in care delivery
 Standardisation of process based on clear specification and articulation
 Use of care bundles
from R Resar, IHI
Level 3+ reliability
Moving towards High Reliability
Anticipation



Preoccupation with failure
Reluctance to simplify interpretations
Sensitivity to operations
Containment


Commitment to resilience
Deference to expertise
Mindfulness: Weick and Sutcliffe
“Together these five processes produce a collective state
of mindfulness. To be mindful is to have an enhanced
ability to discover and correct errors that could escalate
into a crisis.”
Scotland
Prescribing
Dispensing
Medication
Safety
Administration
Reconciliation
Medication: Prescribing Errors
ICU GOSH
Administration
Reconciliation
Olavo Fernandes and Kaveh G. Shojania Medication Reconciliation in the Hospital
Healthcare Quarterly Vol.15 Special Issue 2012
Getting to the third curve
P
e
rf
o
r
m
a
n
c
e
Co-production
Asset
Improvement
Performance
What we
permit
we promote
Understand
the human
factors
Zero
tolerance for
deviance
Change the
parameters
Quality is never an accident;
it is always the result of high
intention, sincere effort,
intelligent direction and skillful
execution; it represents the wise
choice of many alternatives
1941, William A. Foster
@PeterLachman
[email protected]