Quality Improvement Workshop

Transcription

1 Quality Improvement Workshop Internal Medicine Residency Program Dr. Nila Radhakrishnan Dr. Margaret Lo Dr. Rebecca Beyth Dr. Jamie Smith Dr. Arif Ishmael Quality in Patient Care How would you define it?

2 Institute of Medicine (IOM) s Six AIMs Safe Timely Effective Efficient Equitable Patient-Centered IOM Six AIMS

3 Institute of Medicine (IOM) s Sixth AIMs Safe Timely Effective Efficient Equitable Patient-Centered Hospital Compare h.html

4 How would we go about making an improvement? IY

5 AIM Statement 1. We aim to reduce harm and improve patient safety for all of our internal and external customers 2. By June of 2012, we will reduce the incidence of pressure ulcers in the critical care unit by 50% 3. We will reduce all types of hospital acquired infections. 4. Our most recent data reveal that, on average, we reconcile the medications of only 35% of our discharged inpatients. We intend to increase this average system wide to 50% by April 1, 2012, and to 75% by August, 31, 2012.

6 Measures Outcome Measures: where are we ultimately trying to go? Process Measures: Are we doing the right things to get there? Balancing Measures: Are the changes we are making to one part of the system causing problems in other parts of the system? Measures

7 Developing Changes Critical Thinking Benchmarking Taking Patient s Perspective Technology

8 Brief Break

9 PDSA Cycle 4

10

11 Patient Safety Workshop Dr. Nila Radhakrishnan Dr. Margaret Lo Dr. Rebecca Beyth Dr. Jamie Smith Dr. Arif Ishmael In 1999, the Institute of Medicine (IOM) released its landmark report, To Err Is Human, which stated that between 44,000 and 98,000 people die each year in US hospitals due to medical errors.

12 That is more than the number of people who die in a given year from motor vehicle accidents, breast cancer, or AIDs. In fact, every day-and-a-half, a fully-loaded Boeing 747 airplane would have to fall from the sky before airline passenger loss of life would surpass hospital patient loss of life. Since the 1999 IOM report, statistics from around the world continue to point to a very real and significant problem. Consider the following data: A study from 2000 showed that during one year, as many as 18,000 patients in Australia died from medical errors and more than 50,000 patients were disabled. Also in 2000, the Centers for Disease Control and Prevention (CDC) revealed that each year nearly 2 million patients in the United States get an infection while being treated for another illness or injury, and nearly 88,000 die as a direct or indirect result of this infection adding nearly $5 billion to health care costs every year. A 2001 study showed that nearly 12 percent of hospital admissions in the United Kingdom involve some form of adverse event. Medication-related errors are estimated to account for about 7,000 deaths each year in the US, according to a 1997 study, and can increase a 700-bed hospital s operating costs by more than $3 million annually. According to the Centers for Medicare and Medicaid Services (CMS), more than one million patient safety incidents occurred to hospitalized Medicare patients in the US over the years 2002 to 2004, causing more than 250,000 deaths and costing $9.3 billion

13 Sebastian s Story Why do errors happen in medicine? Diagnosing and treating patients is incredibly complex. Practitioners are often not adequately trained or prepared to deliver care as a well-integrated team. Errors often occur as a result of flawed processes or systems of care not because of negligent or irresponsible individuals. The culture of safety "the attitudes, beliefs, perceptions, and values that employees share in relation to safety"10 that exists in most health care organizations is weak compared to many other high-risk, complex businesses such as the airline, petroleum, and nuclear power industries powerful drugs highly technical equipment rapid decisions made under time pressure many caregivers and multiple handoffs limited resources highly acute illness and injuries an environment full of distractions variable patient volume

14 Dennis Dunn Story 5 Things You Can Do Today You are a critical link in the chain of patient safety and must not take that responsibility lightly. Here are five behaviors that any practitioner can do to improve safety for patients in his or her direct care: 1. Follow written safety protocols 2. Speak up when you have concerns 3. Communicate clearly 4. Don t let yourself or others get careless 5. Take care of yourself

15 ER Video Protocols Some work, some don t

16 Insulin Case Root Cause Analysis

17 The RCA seeks to answer four questions: 1. What happened? 2. Why did it happen? 3. What are we going to do to prevent it from happening again? 4. How will we know that the changes we make actually improve the safety of the system? Who should compose the RCA team?

18

19 Vincent et al. go on to identify seven categories of factors that influence clinical practice and medical error. In any given situation, one or more of these can be involved: Institutional Context Organizational and Management Factors Work Environment Team Factors Individual Staff Member Task Factors Patient Characteristics

20 RCA Case Work in groups to come up with causes involved in Margaret s death. The NHS s National Patient Safety Agency suggests that actions should meet the following criteria: Be clearly linked to identified root causes Address all of the root causes Be designed to reduce the likelihood of recurrence or severity of the outcome Be clear and concise and kept to a minimum Be prioritized wherever possible Be SMART: Specific, Measurable, Achievable, Realistic and Timed

21 Strength of Actions The National Center for Patient Safety defines strong, intermediate, and weak actions this way: A strong action is likely to eliminate or greatly reduce the likelihood of an event. It uses physical plant or systemic fixes with application of human factors principles. An intermediate action is likely to control the root cause or vulnerability. It employs human factors principles, but it also relies upon individual action such as a checklist or cognitive aid. A weak action by itself is less likely to be effective. It relies on policies, procedures, and individual action. Q Remove unnecessary and dangerous steps from a process. a) Strong b) Intermediate c) Weak Q Train staff in IV pump use. a) Strong b) Intermediate c) Weak Q Add more nurses to a unit. a) Strong b) Intermediate c) Weak Q Add a checklist for a surgical procedure. a) Strong b) Intermediate c) Weak

22 Q Write a new hospital policy about patient transport. a) Strong b) Intermediate c) Weak Q Replace all IV pumps in the hospital with a single model. a) Strong b) Intermediate c) Weak Q Redesign the crash cart or supply room to keep easily confused drugs apart. a) Strong b) Intermediate c) Weak

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27 QI 102: The Model for Improvement: Your Engine for Change Personal Improvement Project Form Personal Opportunity Statement (Lesson 1) Aim Statement (Lesson 2) Measures (Identify one outcome, two to four process, and one or two balancing; Lesson 3) Outcome Measure: 1) Process Measures: 1) 2) 3) 4) Balancing Measure: 1) 2) Changes to Test (Lesson 4)

28 QI 102: The Model for Improvement: Your Engine for Change Personal Improvement Project PDSA Cycle Form Cycle: Date: Objective of Cycle Collect Data to Develop a Change Test a Change Implement a Change Short Objective of the Cycle: Plan Prediction: Plan for Change or Test: (Who, What, When, Where) Plan for Collection of Data: (Who, What, When, Where) Do: Carry out the Change or Test; Collect Data and Begin Analysis. Study Complete Analysis of Data; Summarize What was Learned. Act Are We Ready to Make a Change? Plan for the Next Cycle. 1

29 Quality Improvement/Patient Safety Knowledge Post Test Name: Date: PGY Level: Question 1: After nine months, hand hygiene rates have significantly improved, but infection rates are only slightly better. Further data analysis reveals a previously unrecognized, significant explanation for the infection rate rise: providers are using antibiotics at a much higher rate in the hospital than is the norm for a hospital like theirs, especially for upper respiratory infections. The extra antibiotic use is predisposing patients to superinfections such as C. difficile. What intervention is most likely to be effective? a. Step up the hand-washing campaign b. Work with physician leaders to educate providers about the high infection rates and high antibiotic use rates c. Design a patient handout describing the risks of a C. difficile infection d. Change the physician incentives so that the physicians are penalized when they prescribe antibiotic Use the following scenarios to answer questions 2-4: An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients. Question 2: Applying the Model for Improvement to the clinic s improvement goal, which of the following is the most reasonable aim statement? a. Implement two PDSA cycles within the next six months of beginning the project. b. Increase the number of patients reporting they are very satisfied with the clinic s scheduling by 50 percent within six months.

30 c. Modify the scheduling process to allow both front desk staff AND nurses to directly schedule appointments d. Create an efficient process for scheduling return appointments at the time of check out. After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to implement an automated reminder phone call 24 hours prior to each clinical appointment. The clinic s improvement team hopes that this small change will improve scheduling. Question 3: What is the team's next step? a. Take a well-deserved break b. Develop their project-level measures c. Test their change plan using the PDSA cycle d. Report their results to clinic leadership and prepare a poster for a national meeting e. Clarify their aim statement Question 4: The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning. What s the next thing the clinic s improvement team should do? a. Change their measures b. Measure to see if the change led to improvement c. Report their results to the clinic leadership and prepare a poster for a national meeting d. Implement the new scheduling process based upon their initial impression of how everything is working. Question 5: After a team training system is implemented in an operating room (OR), a junior circulating nurse notices that a particular anesthesiologist goes missing from the OR at odd times, often seems sluggish, and occasionally slurs her words. Concerned that the physician might be impaired due to medication abuse, the nurse ponders what to do next. What would be the most appropriate way for him to respond? a. Call the physician at home and warn her to stop abusing prescription medication b. Refuse to work with that physician in the future c. Talk to the medical director in confidence d. Warn his friends about working with that physician e. Start a rumor about the physician Question 6: Errors always result in harm a. True b. False

31 Question 7: 1) What is the Swiss cheese model? a. When an individual completing a multiple-step process creates a hole in the process by committing a mistake, which leads to harm b. When a series of errors along multiple steps in a process all line up to lead to an unintended consequence c. When a group discovers that processes have inherent flaws Question 8: Which of the following changes falls under the heading of eliminating waste? a. Physicians type all consult responses directly into a computer rather than writing them in a patient s chart, thus saving paper. b. Dispensers full of hand sanitizer are placed throughout a floor, thus improving compliance with hand hygiene protocols. c. A clinic starts tracking the number of foot exams that diabetic patients receive each year, thus ensuring they receive evidence-based care d. A hospital invites patients to participate in the redesign of one of its centers, thus making them feel like valued members of a care team Question 9: Human factors is the study of: a. Interactions among humans. b. Interactions between humans and machines c. Interactions between humans and the environment. d. All of the above Question 10: An individual is more likely to make an error: a. When he or she is distracted. b. If he or she has less education. c. If he or she isn t trying hard enough. d. All of the above Use the following scenario to answer questions 11-13:

32 You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem. Question 11: Which of the following might be a project-level measure for this effort? a. Average number of minutes between patient arrival at the clinic and completion of check-in b. Number of unexpected events associated with the implementation of a new process c. Average number of students helping to check a patient in d. None of these are project-level measures Question 12: Which of the following is the best way to decide on a sample size (i.e., the number of patients to measure) for the first PDSA cycle of this improvement project? a. That depends on the results of a statistical power analysis b. Collect data on 100 percent of patients for a month c. Collect data on a small, random sample of patients Question 13: As part of your improvement project, you decide to interview a few patients on their way out fo the clinic about their check-in experience and their overall satisfaction with the clinic. This is an example of which of the following measurement techniques? a. Integrating measurement in to the daily routine b. Gathering quantitative data c. Displaying data graphically d. Gathering qualitative data Use the following scenario to answer questions 14 and 15: Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle. Question 14: The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis (RCA) of the incident. If they complete a high-quality RCA, which of the following is an example of the kind of root cause they might identify? a. The nurse did not listen to the patient. b. The patient was male. c. The hierarchy in the operating room had a negative effect upon communication.

33 d. In this particular case, there was nothing that anyone on the surgical team could have done to prevent an error such as this one. Question 15: The team conducting the RCA of the wrong-site surgery realizes that one contributing factor was the pressure on surgical teams to start and end surgeries on time (so as not to disrupt later scheduled procedures). Which of Vincent s seven categories of factors influencing clinical practice does this best illustrate? a. Patient characteristics b. Team factors c. Individual team member d. Organizational and management factors Question 16: Effective team leaders: a. Have multiple degrees. b. Are usually physicians. c. Seek input from all members of the team. d. Know the correct answer in any given situation. Question 17: You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. At this point, what would an effective team leader do? a. Report this adverse event in the anonymous reporting system so that it can be investigated b. Ask administrators to launch an investigation immediately to find out who was responsible for this adverse event c. Add this medication to the patient s allergy list d. Conduct a debriefing Use the following scenario to answer questions 18 through 22. Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient s earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support

34 implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Question 18: In this scenario: a. Rose is right; Dave is just being difficult b. Dave is probably too busy and that is why he is throwing up roadblocks c. Dave s behavior is normal; everyone has some challenges when adapting to new things Question 19: Using Everett Rogers theory of adoption of innovation, which category of adopter best describes Rose? a. Innovator b. Early adopter c. Early majority d. Late majority e. Laggard f. Not enough information to tell Question 20: Using Everett Rogers theory of adoption of innovation, which category of adopter best describes Joan? a. Innovator b. Early adopter c. Early majority d. Late majority e. Laggard f. Not enough information to tell Question 21: Using Everett Rogers theory of adoption of innovation, which category of adopter best describes Dave? a. Innovator b. Early adopter c. Early majority d. Late majority e. Laggard f. Not enough information to tell Question 22: To help Dave adopt the new change, Rose should consider which of the following actions?

35 a. Call Dave s boss b. Provide Dave with literature, including statistics, on the benefits of patient-centered care c. Provide Dave with patient testimonials from the pilot test of the new process, showing how much patients value the bedside change of shift report d. A, B e. B, C Question 23: Janice is a nurse on the orthopedics unit. This night she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later she realizes that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, Why won t someone help me? Janice quickly administers the morphine. When discussing the event with Mrs. Bernardo, the most appropriate initial comment would be: a. Is your pain level better? b. Although it took an hour to get the pain medication, we remain committed to making sure you get excellent care. c. I apologize for the delay in your morphine. d. Pain medication can be very tricky, so we are always careful not to give too much, too quickly. Sometimes that means that it takes a while to get your pain under control, but that is for the best. Question 24: Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain medication? a. It is not necessary to apologize in this case. b. An apology is needed to maintain provider-patient trust. c. All institutions require an apology. d. An apology will prevent the patient relations department from becoming involved. Question 25: Janice gives the following apology to Mrs. Bernardo: Mrs. Bernardo, there was a delay in you receiving your pain medication that should not have happened. I am very sorry that you had unnecessary pain. The doctor gave me the order to give you a dose of morphine. However, I was caring for another patient who had fallen, and I got distracted and did not give you the medication as quickly as I should have. Again, I just want you to know how sorry I am that this happened. Which one of Lazare s four components of an apology is missing in Janice s apology? a. Acknowledgment b. Explanation c. Expression of remorse or shame

36 d. Reparation

37 Quality Improvement/Patient Safety Knowledge Post Test Name: Date: PGY Level: Question 1: After nine months, hand hygiene rates have significantly improved, but infection rates are only slightly better. Further data analysis reveals a previously unrecognized, significant explanation for the infection rate rise: providers are using antibiotics at a much higher rate in the hospital than is the norm for a hospital like theirs, especially for upper respiratory infections. The extra antibiotic use is predisposing patients to superinfections such as C. difficile. What intervention is most likely to be effective? a. Step up the hand-washing campaign b. Work with physician leaders to educate providers about the high infection rates and high antibiotic use rates c. Design a patient handout describing the risks of a C. difficile infection d. Change the physician incentives so that the physicians are penalized when they prescribe antibiotic Use the following scenarios to answer questions 2-4: An orthopedic clinic in a busy metropolitan area would like to improve its patient scheduling process. More specifically, the clinic wants to improve its efficiency and the satisfaction of its patients. Question 2: Applying the Model for Improvement to the clinic s improvement goal, which of the following is the most reasonable aim statement? a. Implement two PDSA cycles within the next six months of beginning the project. b. Increase the number of patients reporting they are very satisfied with the clinic s scheduling by 50 percent within six months.

38 c. Modify the scheduling process to allow both front desk staff AND nurses to directly schedule appointments d. Create an efficient process for scheduling return appointments at the time of check out. After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to implement an automated reminder phone call 24 hours prior to each clinical appointment. The clinic s improvement team hopes that this small change will improve scheduling. Question 3: What is the team's next step? a. Take a well-deserved break b. Develop their project-level measures c. Test their change plan using the PDSA cycle d. Report their results to clinic leadership and prepare a poster for a national meeting e. Clarify their aim statement Question 4: The orthopedic clinic plans the change to improve scheduling, and then it carries out a small test of change with three patients on Tuesday morning. What s the next thing the clinic s improvement team should do? a. Change their measures b. Measure to see if the change led to improvement c. Report their results to the clinic leadership and prepare a poster for a national meeting d. Implement the new scheduling process based upon their initial impression of how everything is working. Question 5: After a team training system is implemented in an operating room (OR), a junior circulating nurse notices that a particular anesthesiologist goes missing from the OR at odd times, often seems sluggish, and occasionally slurs her words. Concerned that the physician might be impaired due to medication abuse, the nurse ponders what to do next. What would be the most appropriate way for him to respond? a. Call the physician at home and warn her to stop abusing prescription medication b. Refuse to work with that physician in the future c. Talk to the medical director in confidence d. Warn his friends about working with that physician e. Start a rumor about the physician Question 6: Errors always result in harm a. True b. False

39 Question 7: 1) What is the Swiss cheese model? a. When an individual completing a multiple-step process creates a hole in the process by committing a mistake, which leads to harm b. When a series of errors along multiple steps in a process all line up to lead to an unintended consequence c. When a group discovers that processes have inherent flaws Question 8: Which of the following changes falls under the heading of eliminating waste? a. Physicians type all consult responses directly into a computer rather than writing them in a patient s chart, thus saving paper. b. Dispensers full of hand sanitizer are placed throughout a floor, thus improving compliance with hand hygiene protocols. c. A clinic starts tracking the number of foot exams that diabetic patients receive each year, thus ensuring they receive evidence-based care d. A hospital invites patients to participate in the redesign of one of its centers, thus making them feel like valued members of a care team Question 9: Human factors is the study of: a. Interactions among humans. b. Interactions between humans and machines c. Interactions between humans and the environment. d. All of the above Question 10: An individual is more likely to make an error: a. When he or she is distracted. b. If he or she has less education. c. If he or she isn t trying hard enough. d. All of the above Use the following scenario to answer questions 11-13:

40 You volunteer at a student-run clinic associated with your academic health center. As a member of the student board, you are constantly looking for ways to improve the clinic. One common complaint is that it takes too long to check patients in once they arrive, and you decide to tackle this problem. Question 11: Which of the following might be a project-level measure for this effort? a. Average number of minutes between patient arrival at the clinic and completion of check-in b. Number of unexpected events associated with the implementation of a new process c. Average number of students helping to check a patient in d. None of these are project-level measures Question 12: Which of the following is the best way to decide on a sample size (i.e., the number of patients to measure) for the first PDSA cycle of this improvement project? a. That depends on the results of a statistical power analysis b. Collect data on 100 percent of patients for a month c. Collect data on a small, random sample of patients Question 13: As part of your improvement project, you decide to interview a few patients on their way out fo the clinic about their check-in experience and their overall satisfaction with the clinic. This is an example of which of the following measurement techniques? a. Integrating measurement in to the daily routine b. Gathering quantitative data c. Displaying data graphically d. Gathering qualitative data Use the following scenario to answer questions 14 and 15: Mr. Reynolds, a 75-year-old man, recently suffered from a wrong-site surgery. His left ankle was operated upon rather than his right ankle. Question 14: The surgical staff that operated on Mr. Reynolds is embarking on a root cause analysis (RCA) of the incident. If they complete a high-quality RCA, which of the following is an example of the kind of root cause they might identify? a. The nurse did not listen to the patient. b. The patient was male. c. The hierarchy in the operating room had a negative effect upon communication.

41 d. In this particular case, there was nothing that anyone on the surgical team could have done to prevent an error such as this one. Question 15: The team conducting the RCA of the wrong-site surgery realizes that one contributing factor was the pressure on surgical teams to start and end surgeries on time (so as not to disrupt later scheduled procedures). Which of Vincent s seven categories of factors influencing clinical practice does this best illustrate? a. Patient characteristics b. Team factors c. Individual team member d. Organizational and management factors Question 16: Effective team leaders: a. Have multiple degrees. b. Are usually physicians. c. Seek input from all members of the team. d. Know the correct answer in any given situation. Question 17: You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects. At this point, what would an effective team leader do? a. Report this adverse event in the anonymous reporting system so that it can be investigated b. Ask administrators to launch an investigation immediately to find out who was responsible for this adverse event c. Add this medication to the patient s allergy list d. Conduct a debriefing Use the following scenario to answer questions 18 through 22. Your organization is implementing a new change-of-shift report that will be given at the patient bedside, rather than in a hallway or some location beyond the patient s earshot. The goal is to increase patient involvement in care. Rose created the improvement team that designed the change-of-shift report form and is very passionate about patient involvement. She has attended several conferences on the topic, suggested the idea for the bedside change-of-shift report, and encouraged organizational leadership to support

42 implementing the form. Joan is also excited about the report, but has not been involved since the beginning. She, however, has offered her unit to be the first to pilot test the form. Dave is resisting the form; he feels that patients are involved enough and there is no need to have a specific change-of-shift report that is given at the bedside. Rose is frustrated that Dave can't let go. She thinks he is being difficult. Question 18: In this scenario: a. Rose is right; Dave is just being difficult b. Dave is probably too busy and that is why he is throwing up roadblocks c. Dave s behavior is normal; everyone has some challenges when adapting to new things Question 19: Using Everett Rogers theory of adoption of innovation, which category of adopter best describes Rose? a. Innovator b. Early adopter c. Early majority d. Late majority e. Laggard f. Not enough information to tell Question 20: Using Everett Rogers theory of adoption of innovation, which category of adopter best describes Joan? a. Innovator b. Early adopter c. Early majority d. Late majority e. Laggard f. Not enough information to tell Question 21: Using Everett Rogers theory of adoption of innovation, which category of adopter best describes Dave? a. Innovator b. Early adopter c. Early majority d. Late majority e. Laggard f. Not enough information to tell Question 22: To help Dave adopt the new change, Rose should consider which of the following actions?

43 a. Call Dave s boss b. Provide Dave with literature, including statistics, on the benefits of patient-centered care c. Provide Dave with patient testimonials from the pilot test of the new process, showing how much patients value the bedside change of shift report d. A, B e. B, C Question 23: Janice is a nurse on the orthopedics unit. This night she is caring for five patients, as well as a new admission from the emergency department. While juggling patient care, she calls the on-call resident (house officer) about Mrs. Bernardo, who is in significant pain from a fractured hip. Janice hastily writes down the morphine order from the resident and is then called away when another patient falls out of bed. An hour later she realizes that she has not yet given Mrs. Bernardo her pain medication. When she rushes into the room, the patient is crying and asking, Why won t someone help me? Janice quickly administers the morphine. When discussing the event with Mrs. Bernardo, the most appropriate initial comment would be: a. Is your pain level better? b. Although it took an hour to get the pain medication, we remain committed to making sure you get excellent care. c. I apologize for the delay in your morphine. d. Pain medication can be very tricky, so we are always careful not to give too much, too quickly. Sometimes that means that it takes a while to get your pain under control, but that is for the best. Question 24: Why is it important for Janice to apologize to Mrs. Bernardo for the delay in her pain medication? a. It is not necessary to apologize in this case. b. An apology is needed to maintain provider-patient trust. c. All institutions require an apology. d. An apology will prevent the patient relations department from becoming involved. Question 25: Janice gives the following apology to Mrs. Bernardo: Mrs. Bernardo, there was a delay in you receiving your pain medication that should not have happened. I am very sorry that you had unnecessary pain. The doctor gave me the order to give you a dose of morphine. However, I was caring for another patient who had fallen, and I got distracted and did not give you the medication as quickly as I should have. Again, I just want you to know how sorry I am that this happened. Which one of Lazare s four components of an apology is missing in Janice s apology? a. Acknowledgment b. Explanation c. Expression of remorse or shame

44 d. Reparation

45 Post test Answer Key 1 B 2 B 3 C 4 B 5 C 6 B 7 B 8 A 9 D 10 A 11 A 12 C 13 D 14 C 15 D 16 C 17 D 18 C 19 A 20 B 21 E 22 E 23 A 24 B 25 D

46 Quality Improvement/Patient Safety Knowledge Pre Test Name: Date: PGY Level: Did you have QI/PS training prior to residency? Y N Use the following scenario to answer question 1: Question 1: Ben, a 36-year-old patient with Type I diabetes mellitus and kidney failure, comes to the hospital to have a special arteriovenous (AV) fistula placed in his arm to allow him to begin dialysis in a few weeks. This procedure normally allows the patient to go home that evening. When Ben wakes up after anesthesia in the recovery room, he sees a bandage on his right arm. He is confused, because the fistula was supposed to be placed on the left arm. The recovery nurse informs him the fistula is on the right. What should happen next? a. The surgeon should lose his or her license b. The mistake should be communicated to Ben and hospital s administrators c. Ben should immediately be offered a financial settlement d. The mistake should be posted on a blog along with an explanation of the events e. The entire surgical team should be reprimanded, as it was not only the responsibility of the surgeon Question 2: What does patient safety mean, according to the World Health Organization? a. Freedom from unnecessary harm or potential harm associated with health care

47 b. Freedom from errors or potential errors associated with health care c. Freedom from death associated with health care d. Receiving the most state-of-art care possible Use the following scenario to answer questions 3-5: Transcendental Nursing Home is working on decreasing its rates of catheter-associated urinary tract infections (UTIs) among its residents. While reviewing data, the improvement team notices that the UTI rate on Floor 3 is half that of the rest of the floors. They decide to visit the unit and find out what it is doing differently. Question 3: Which component of Deming s theory of profound knowledge is the team about to harness? a. Systems thinking b. Variation c. Theory of Knowledge d. Psychology Question 4: After speaking with caregivers on Floor 3, the improvement team discovers that there is a particularly dedicated head nurse on the unit whose mother died after a catheter-associated UTI. This nurse orients all new providers and also provides feedback when she sees that catheters are being placed unnecessarily in patients. Which component of Deming s theory of profound knowledge does this nurse s actions best represent? a. Systems thinking b. Variation c. Theory of Knowledge d. Psychology Question 5: In their review of data, the Transcendental improvement team notices that one unit has infection rates that are sky-high. Frustrated, the leadership decides to replace all the providers on that unit except the three with the highest seniority. What is the likely outcome, and why? a. Infection rates will not change because the leaders have not changed the system of care b. Infection rates will not change because the three caregivers with seniority are probably negligent, like their peers who were fired c. Infections rates will get better because the leaders have fixed the system d. Infections rates will get better because the leaders have removed sources of variation Question 6: At Springfield Community Hospital, the rate of Clostridium difficile colitis has doubled over the past year. After reviewing the data, the hospital s senior leaders conclude that this is due to poor hand hygiene on the part of the staff. They decide to start a hand-washing campaign and post signs all over the hospital reminding practitioners to wash their hands.

48 What type of error is this intervention best designed to address? a. Mistake b. Slip c. Lapse d. Error of planning e. Violation Question 7: A diabetic patient comes to an emergency department with extremely high blood glucose levels. The resident, nearing the end of an 18-hour shift, writes a prescription for insulin followed by the letter U for units. But in her exhaustion, she completes the U so it looks like an extra zero. As a result, the pharmacist dispenses a dose that s ten times stronger than the one the patient needs. Which of the following is an endogenous cause of the resident s error? a. Long work schedule b. Fatigue c. Inadequate training d. Poor handwriting Question 8: Which of the following is an exogenous cause of the resident s error? a. Long work schedule b. Fatigue c. Inadequate training d. Poor handwriting Question 9: Gathering and reviewing data during an improvement project that is, measuring helps you answer which of the three questions of the Model for Improvement? a. How will we know that a change is an improvement? b. What are we trying to accomplish? c. What changes can we make that will result in improvement? Question 10: Human factors is the study of: a. Interactions among humans. b. Interactions between humans and machines c. Interactions between humans and the environment. d. All of the above Use the following to answer question You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival

49 to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success. Question 11: The care protocol was successful at the other hospital. Why would it be important to test this proven change at your hospital? a. Because the last success may have been a fluke. b. So that you can publish your results. c. Because this change may not be as effective in your hospital. d. In order to demonstrate the ability of this protocol to improve care in other hospitals for those that created it Question 12: After several tests, you decide to try implementing a modified version of the protocol at your institution. Which of the following might you do within the S portion of your next PDSA cycle? a. Develop the final plan for the protocol implementation. b. Document unexpected observations. c. Analyze information collected. d. Strategize how to move this to another hospital in the system. Question 13: An individual is more likely to make an error: a. When he or she is distracted. b. If he or she has less education. c. If he or she isn t trying hard enough. d. All of the above Question 14: Root cause analyses can be useful in health care because: a. They help to assign blame. b. They help to identify system failures that can be corrected. c. They are often quick and simple to perform. Use the following to answer questions You re trying to improve patient satisfaction scores in your hospital s emergency department. You decide to poll 40 patients a day for three weeks. Your charge nurse says that the quality of service really fluctuates depending on the time of day. So your daily sample consists of 10 patients polled at 8 AM, another 10 at noon, another 10 at 5 PM, and the final 10 at 9 PM. Question 15:

50 This is an example of what kind of sampling? a. Simple random b. Judgment c. Proportional stratified random d. Mechanical Question 16: 1) Given your data collection strategy thus far, what might be the best way to stratify your data on patient satisfaction once it is collected? a. By patient age b. By time polled c. By sex of the patient d. By sex of the provider Question 17: LaTonya, a young woman with diabetes, dies after being admitted for a kidney infection. What might an RCA NOT be able to uncover? a. The medical resident caring for her did not know the appropriate antibiotics for this type of infection. b. There are 23 steps between ordering an antibiotic and administering it on the unit. c. The new electronic medical system does not have a mechanism to flag stat antibiotics for pharmacy. d. Fatigue among residents is contributing to unsafe care. Use the following scenario to answer question 18: On a particular busy night in the emergency department, a patient comes in with chest pain. The triage nurse, who has been on the job only two days, follows protocol and brings the patient in immediately. An electrocardiogram is done within five minutes and shows a possible heart attack. The cardiologist is called immediately, and 25 minutes after arriving in the emergency department, the patient is in the cardiac catheterization lab. Question 18: The efficient care in this case is an example of: a. Commitment to quality by a fabulous triage nurse. b. The excellence that s only possible at an academic medical center. c. The benefits of having a clear plan for emergencies. d. The need to publically report patient outcomes. Use the following scenario to answer question 19: On a particularly busy night in the emergency department, a patient comes in with chest pain. The triage nurse, who s been on the job only two days, takes the patient s information, fills out the form, and puts the

51 patient s chart on the rack so he ll be seen in the order in which he arrived. She mentions to a passing nurse, There s a patient here who has pain he s waiting to be seen. Thirty minutes later, still waiting to be seen, the patient collapses in the waiting room. Question 19: What likely contributed to this outcome? a. The lack of a shared plan for patients with chest pain resulted in a failure to act quickly. b. The high patient volume caused a long delay in caring for a patient with a critical condition. c. A new nurse was placed in triage, which was not safe. d. No clear standard of care exists for chest pain patients, so the nurse couldn t have known what to do. Consider the following example when answering questions 20-22: Your organization is implementing a fall risk assessment form to help identify patients at risk for falls. The team in charge of the initiative has designed the screening form to identify five critical pieces of information: patient medications, patient age, reasons for admission, patient mental state, and previous falls. To ensure that every nurse captures all five data points for every patient, the organization is offering a prize a trip to Las Vegas for the nurse who completes the most forms correctly in a three-month period. Question 20: The vacation to Las Vegas is an a. Intrinsic motivator b. Extrinsic motivator c. Opportunity for further continuing education Question 21: The work of W. Edwards Deming and Alfie Kohn suggests that after the three-month period is over and the Las Vegas trip has been awarded, the following will likely happen: a. Nurses will use the screening form more. b. Nurses will use the screening form less. c. There will be no change to the nurses use of the screening form. Question 22: According to the work of Deming and Kohn, a better motivator for using the checklist might be: a. A trip to Hawaii b. A bonus c. Tying patient falls into performance reviews and compensation d. Showing that using the form can reduce the likelihood of patient falls Use the following scenario to answer questions 23 and 24:

52 You re a new resident (house officer). At 2:00 AM you receive a phone call about a patient you are covering. A diabetic, the patient has an elevated blood sugar of 375. You order 12 units of NovoLog (rapid-acting) insulin and ask the nurse to check the sugar again in one hour and call you back. One hour later, the sugar is 280, so you order another 10 units. By 4:00 AM, the patient s sugar is dangerously low at 45. You realize that NovoLog insulin takes two to three hours to reach peak effect. By rechecking the patient s glucose after only one hour and giving more insulin so quickly, you set the patient up for an episode of hypoglycemia. Question 23: Why might it be difficult to discuss what happened with the patient? a. The medical explanation is too complex for patients to understand. b. It is hard to admit that you ve caused harm when the point of your job is to help people. c. The explanation should come from the nurse. d. Discussing what happened with the patient will increase the likelihood of a lawsuit. Question 24: Why is it important to communicate with the patient about this event? a. Open sharing of information is necessary if patients are to trust their caregivers. b. As the physician, you might lose your medical license if you fail to discuss the adverse event with the patient. c. Communication prevents any risk of a lawsuit. d. Communication is required by the Accreditation Council of Graduate Medical Education, which oversees all residency programs in the US and Canada. Question 25: A medical unit in a hospital is in the midst of hiring some new physicians. During an orientation for new employees, a senior leader stands up and says, We expect that the same rules apply to everyone on the unit, regardless of position. Which aspect of a culture of safety does this unit seem to value? a. Psychological safety b. Fairness c. Transparency d. None of these

53 1 B 2 A 3 B 4 D 5 A 6 C 7 B 8 A 9 A 10 D 11 C 12 C 13 A 14 B 15 B 16 B 17 A 18 C 19 A 20 B 21 B 22 D 23 B 24 A 25 B Pre test Answer Key

54 Case Study Patient Safety 104: Root Cause and Systems Analysis Margaret is an elderly woman who has been admitted to an academic medical center for breathing problems. She has some trouble hearing and has some memory problems as well. Peter is a well-respected nurse on the medical unit. He has been working there for five years, and he s recently been helping new nurses get oriented to work in his part of the hospital. Today, he is working with Amy, a new graduate who just passed her boards and received her RN. Jorge, a respiratory therapist, is called to see Margaret to help with her breathing. He notes that she is not getting enough oxygen using just the nasal prongs, and he switches her to an oxygen mask, which improves her symptoms. Jorge sees Peter in the hallway and says, Hey, Peter, I upped her oxygen, as they pass each other on the way to their next tasks. It is a busy day for Jorge, who figures he will write his notes in the chart later. At 3 pm, Margaret is scheduled to go for a test in the radiology department on the other side of the hospital. Teddy, the patient transporter, arrives to take Margaret to her test. Peter, the experienced nurse, is in another patient s room, assisting one of the doctors with the placement of a sterile central line. When Teddy asks if there are any special concerns with Margaret, Amy, the new nurse, replies, No, she s all set! If Amy had been told about Margaret s oxygen mask, she would have accompanied her to the test. While being transported, Margaret knocks her mask off her face. When she arrives in the radiology department for her test, she is not breathing. The code team is called, but they are unable to revive her. 1

55 Case Study Patient Safety 104: Root Cause and Systems Analysis Margaret is an elderly woman who has been admitted to an academic medical center for breathing problems. She has some trouble hearing and has some memory problems as well. Peter is a well-respected nurse on the medical unit. He has been working there for five years, and he s recently been helping new nurses get oriented to work in his part of the hospital. Today, he is working with Amy, a new graduate who just passed her boards and received her RN. Jorge, a respiratory therapist, is called to see Margaret to help with her breathing. He notes that she is not getting enough oxygen using just the nasal prongs, and he switches her to an oxygen mask, which improves her symptoms. Jorge sees Peter in the hallway and says, Hey, Peter, I upped her oxygen, as they pass each other on the way to their next tasks. It is a busy day for Jorge, who figures he will write his notes in the chart later. At 3 pm, Margaret is scheduled to go for a test in the radiology department on the other side of the hospital. Teddy, the patient transporter, arrives to take Margaret to her test. Peter, the experienced nurse, is in another patient s room, assisting one of the doctors with the placement of a sterile central line. When Teddy asks if there are any special concerns with Margaret, Amy, the new nurse, replies, No, she s all set! If Amy had been told about Margaret s oxygen mask, she would have accompanied her to the test. While being transported, Margaret knocks her mask off her face. When she arrives in the radiology department for her test, she is not breathing. The code team is called, but they are unable to revive her. 1