Transcript Ensuring a Safe Journey

Mark Ross, MS HROD
Director Ambulatory Surgery Service
Sutter Roseville Medical Center
Roseville, CA
Ensuring a
Safe Journey
Patients First, Always
Ensuring a Safe
Journey
Ensuring a
Safe Journey
Ensure that every patient, visitor, and staff
experiences a “safe journey” through our
healthcare system that is
free of risks
which could or have caused harm.
Patients First, Always
Ensuring a Safe
Journey
Outcomes of a Safe Journey Program
• Promotes trust and learning
• Clarifies responsibility and enables accountabilities
to be exercised Identifies system deficiencies and
shortcuts
• Provides a mechanism for better relationships
between managers and staff.
• Takes into account human factors
• Provides a framework for assessing culpability and
accountability
• Does not mean “blame free”
Patients First, Always
Ensuring a Safe
Journey
13,000
diseases,
syndromes, &
injuries
Patients First, Always
Ensuring a Safe
Journey
• Diagnoses 250
different
medical
conditions
• Considers 900
other active
medical
conditions
• Prescribes 300
medications
• Orders 100
different lab
tests
Patients First, Always
Ensuring a Safe
Journey
Why Errors Occur in Healthcare
•Patients are individual and complex
•Coordination of care with other providers and
departments
•Hand-offs in care
•Lack of standardized processes
•Communication issues
•Hierarchal Structure
•Silo thinking
•Patient Acuity, volume and workloads
Patients First, Always
Ensuring a Safe
Journey
Patients First, Always
Ensuring a Safe
Journey
70% of sentinel events have communication as primary root
cause (Joint Commission, 2004 & Arch Intern Med, 2007)
75% of adverse events and close calls have communication
breakdowns as primary contributing factor (Jt Comm J Qual
Patient Saf, 2007)
ORs have a 30% communication failure rate (Qual Safe Health
Care, 2004)
Teamwork failure implicated in 50% of OR adverse events
(Surgery, 2003)
Communication failure reported in 91% of AMC adverse events
(Acad Med, 2004)
Patients First, Always
Ensuring a Safe
Journey
“ ….the universal constant is that
human infallibility is impossible and
those who build a system that
depends on an absence of serious
human mistakes will fail utterly.”
John Nance in “Why Hospitals Should Fly”
Patients First, Always
Ensuring a Safe
Journey
Focus on the Outputs – Outdated Approach
Shame &
Blame
System
Design
Human
Errors
Adverse
Events
Behavioral
Choices
No Harm
No Foul
Working it here
(80%)
Before it leads to here (20%)
Patients First, Always
Ensuring a Safe
Journey
Whack a Mole
Patients First, Always
Ensuring a Safe
Journey
Whack-a-Mole
“Whack-a-Mole may be addicting for its simplicity, but it’s not a
productive way to deal with adverse events. Whether it’s our
attitude towards spilt milk at the dinner table or our attitude
toward the airline pilot who misses an item on the checklist,
we simply cannot believe that an expectation of perfection will
get us the results we want. We spend far too much time
looking at the severity of the adverse outcome (how bad was
it) and who was the unfortunate soul to be closest to the harm.
In turn, we spend far too little time addressing the system
design that got us there and the behavioral choices of the
humans in those systems that might have ultimately
contributed to the adverse outcome.”
David Marx
Whack-a-Mole
Patients First, Always
Ensuring a Safe
Journey
“Most healthcare providers choose a life of
service. They put themselves in harm’s way
to care for others. They expect a lot of
themselves as professionals. Yet, they
remain fallible human beings, regardless of
any oaths to do no harm. They are going to
make mistakes and occasionally drift into
risky places. The future of our nation’s
health depends upon our ability to learn from
their errors and at-risk behaviors.”
David Marx, JD
Whack-a-Mole
Patients First, Always
Ensuring a Safe
Journey
Focus on the Inputs to Manage the Outputs
System
Design
Human
Errors
Adverse
Events
Behavioral
Choices
Working it here
(80%)
Before it leads to here (20%)
Patients First, Always
Patients First, Always
Ensuring a Safe
Journey
Create a Safe
Place to
Identify and
Discuss Risk
“ Since human error is inevitable, the
only way to keep error from hurting
patients is by creating collegial
interactive teams whose members,
acting together, can catch and
neutralize one another's mistakes."
John Nance - "Why hospitals should fly
Responsibilities and Authority to
Intervene to Protect Patient Safety
Patients First, Always
Ensuring a Safe
Journey
Drift
The better we get at a profession, the more apt
we are to use work arounds that have not
produced problems in the past. We begin to use
them as if they are the accepted policy/procedure.
We DRIFT away from the actual procedure.
You are going to DRIFT when you think you're in
a safe place.
Patients First, Always
Ensuring a Safe
Journey
MEDICAL DRIFT
Can cause Patient HARM
Not checking the X-ray to make sure the correct side is up.
Now the right side is the left side. Wrong side surgery.
Time Out. Read out the procedure ... right side, but don’t
make sure that everyone stops and acknowledges.
Wrong side surgery.
Doctor orders Norcor. Nurse gives norcor. Pt allergic.
Medication error. Allergy sticker on front of chart.
Patients First, Always
Ensuring a Safe
Journey
Patient Safety Report (PSR)
• Staff are encouraged to write a PSR on
anything that happens out of the ordinary.
• More PSR’s are good, not bad. They allow us
to see where are systems can be better.
• Don’t whack a mole every time there is a
problem. Work together to fix the problem
and staff will see the benefits in reporting.
Patients First, Always
Ensuring a Safe
Journey
Good Catch Program
1. Speak up when you see someone not
following a policy or procedure. Stop for
patient safety.
2. Everyone is equal when it comes to patient
safety. There is no hierarchy in a good catch
program.
3. Be transparent with good catches. Let
everyone know.
4. Review the good catch for system faults.
Patients First, Always
Ensuring a Safe
Journey
Design
Safe
Systems to
Mitigate
Risk
“Our systems are too
complex to expect merely
extraordinary people to
perform perfectly 100% of
the time. We, as leaders,
have a responsibility to put
into place systems to
support safe practice.”
James Conway, IHI
Patients First, Always
Ensuring a Safe
Journey
How do we build better systems?
What happened?
What normally happens?
What does procedure require?
Why did it happen?
How are we managing it?
Evaluate
Patients First, Always
Sterile Processing
What Happened
Three good catches in the period of a month where OR Tech discovered debris on an instrument before
the case started.
Investigate
Assemble a resource team
What normally happens
Instruments in basin after case. Sprayed with gel. Wheeled into Decontam. Scubbed. Put into
ultrasonic washer. Removed and put into instrument washer. Inspected while assembling into trays.
Wrapped and put into Sterilizer. Put on shelf for next use. (none if this written down). OR Tech to inspect
instruments while setting up table before case. Staff member on LOA so a variety of Techs/Registry filling
in.
What does this procedure require
Instrument opened in basin. Sprayed with gel. Cannulas etc sprayed down the tube. Wheeled into
Decontam. Scrubbed, not just soaked and rinsed. Put into ultrasonic wash (Use indicator to make sure ultrasonic is
working). Remove and put pipe cleaners in cannulas etc and then into Instrument washer. Remove pipe
cleaners and inspect for debris. Assembling into trays. Wrap and put into Sterilizer. OR Tech to inspect
instruments while setting up table before case. If debris found on instrument, but on back table and alert
charge nurse/Sterile Processing so investigation can be done.
Patients First, Always
Ensuring a Safe
Journey
Why did it happen
Human Error – No consistent spraying of instruments before coming to
decontam
Instruments not cleaned thoroughly in decontam
Debris not pick up when putting instruments together
Too many different staff and registry staff covering for LOA.
System Design –No way to check lumins and cannulas for debris.
Not evaluating if protocols are followed.
Not evaluating success rate.
Patients First, Always
Ensuring a Safe
Journey
How are we managing it.
•At the end of a case all instruments will be opened and sprayed with solution to loosen blood and
foreign materials. Solution is to be sprayed inside cannulas and shavers.
•Once carts are in decontam, all instruments are to be scrubbed. Cannulas and shavers are to have
brushes run through them and water rinsed through the inside until no visible material can be seen
coming through.
•A pipe cleaner is put through the middle of all cannulas.
•All instruments are then put into the ultrasonic soak.
•After the ultrasonic cycle is completed, the instruments are put through the washer.
•The instruments are taken from the washer into the clean side of sterile processing. Instruments are
scanned for foreign material and pipe cleaners removed. If there is any foreign material on the pipe
cleaner, the instrument is put back into decontam to start the process over.
•Instruments are assembled in the appropriate trays and wrapped.
•Once wrapped, the instruments are put into the autoclave for final sterilization.
•When the sterilization cycle is complete, instruments are put away on racks to be picked for cases.
•The last check is done by the OR Techs at the time they open instruments for the case. At that time
they inspect all instruments as they are openned on their table. If there is a problem, the instrument is
place of the back table and they report it to the RN and/or Sterile Processing Supervisor. The case is
then reviewed and the appropriate actions taken to prevent further occurrence
Patients First, Always
Ensuring a Safe
Journey
Evaluation
• Random checks on all personnel to make sure
they are following protocols.
• Log of carts coming back that are not
thoroughly sprayed.
• Instruments sets randomly opened to see if
there is any debris.
• Log of instruments pulled by OR Tech and
placed on back table.
Patients First, Always
Ensuring a Safe
Journey
JUST CULTURE
Manage
Behavioral
Choices in a
Fair and Just
Manner
Acknowledges that no system can be
designed to produce perfect results –
because we do not start with perfect
components. All humans are destined to
make mistakes, and destined to drift into atrisk behavioral choices, regardless of how
well the system is designed. We must view
the quality of the systems we design around
our employees, and their safe behavioral
choices within those systems, as the two
inputs to be managed. The focus is shifted
from errors and outcomes, to system design
and behavioral choices.
1. Human Error
2. At-Risk Behavior
3. Reckless Behavior
Patients First, Always
Ensuring a Safe
Journey
Just Culture Overview
“The single greatest impediment to error
prevention in the medical industry is that
we punish people for making mistakes.”
Dr. Lucian Leape
Professor, Harvard School of Public Health
Testimony before Congress on Health Care Quality Improvement
Patients First, Always
Ensuring a Safe
Journey
Human Error
Patients First, Always
Ensuring a Safe
Journey
Human Error
• Unintended human act that does not achieve
the desired goal
• A planned action is not carried out as
intended
• Mistake, slip, lapse
• No discipline because no intent
Console
Patients First, Always
Ensuring a Safe
Journey
Scenario
Pt in PACU. Front of chart lists Allergy to
Norco. Drs order is for Norco. RN give
patient Norco. Allergic reaction requires
Benadryl to reduce rash and itching.
Patients First, Always
Ensuring a Safe
Journey
Consoling the Human Error
• Consoling the person simply acknowledges that you know it was
unintentional
• It demonstrates compassion
• It promotes learning because people will be more willing to
describe errors
• Consoling doesn’t give permission to make errors
RN - I just forgot to check the Allergy sticker. I always check but we were
so busy today. I can’t believe I did that.
Mgr - Listen, I know it was a honest mistake and I know it can get really
busy sometimes. We never expect you to go faster than what is safe. In
the future take the time to do what is right. Do you think there is anything
that could be done to prevent this from happening again?
Patients First, Always
Ensuring a Safe
Journey
At-Risk Behavior
• We are programmed to drift into unsafe habits
• We lose perception of the risk of everyday
behaviors
• We may even believe the risk is justified
Coach
Patients First, Always
Ensuring a Safe
Journey
At Risk Behavior
Patients First, Always
Coaching the At Risk Behavior
• Supportive discussion with the employee on
the need to engage in safe behavioral choices.
RN - I saw the doctors order. I assume the doctor wouldn’t write an
order for a drug that the patient is allergic to. This has never happened
before.
Mgr - Remember, there is a protocol to follow, you need to check the
allergy sticker every time before giving a new drug. That protocol is
there because Doctors don’t always check allergies before ordering a
drug. You are the patients advocate. You are their line of defense, you
are protecting them from harm.
Patients First, Always
Ensuring a Safe
Journey
Reckless Behavior
• Behavioral choice to consciously disregard a
substantial and unjustifiable risk
• Intentional risk taking
• Manage through disciplinary action
Punitive Action
Patients First, Always
Ensuring a Safe
Journey
Reckless
Patients First, Always
Ensuring a Safe
Journey
Punitive Action
RN - Most of the medication allergies that pts report are
bogus. I had already drawn up the norcor. It was getting late
and I just wanted to get this patient out the door.
Mgr - So you check the allergies and chose to disregard it
because you wanted to get the patient out the door. That is
total disregard for the patient’s well being. You put your want
to go home before your patients well being. I am going to
write this up and recommend disciplinary action.
Patients First, Always
Ensuring a Safe
Journey
The Just Culture Algorithm
Managers must have a good sense of what to
do when a breach occurs. What should a
manager do when a employee has not lived
up to our shared values? The Just Culture
Algorithim is meant to be the key to answer
this question.
Patients First, Always
Ensuring a Safe
Journey
Patients First, Always
Ensuring a Safe
Journey
Why is it so important to
ENSURE a SAFE JOURNEY
Patients First, Always
Ensuring a Safe
Journey
Patients First, Always
Ensuring a Safe
Journey
Patients First, Always
Ensuring a Safe
Journey