Fostering a Culture of Safety
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1 Fostering a Culture of Safety June 11, 2017 Alabama Society of Health System Pharmacists Presenter: Trey Gwin, RPh, MBA, Medication Safety Coordinator, Infirmary Health
2 Financial Disclosure The speaker for today s talk, Trey Gwin, RPh, MBA, currently serving as the Medication Safety Coordinator for Infirmary Health, has no relevant financial relationships or conflicts of interest to disclose.
3 Learning Objectives Pharmacists Upon completion of this program the pharmacist will be able to: Recognize and identify a medication error Evaluate and categorize a medication error by level of risk/harm category Interpret and analyze trends in medication error data Communicate lessons learned and apply them in practice to prevent recurrence
4 Learning Objectives Pharmacy Technicians Upon completion of this program the pharmacy technician will be able to: Recognize the pharmacy technician s role in safe medication use Discuss the value of a pharmacy technician safety advocate/coach
5 Summary Discuss the culture of safety Describe characteristics of highly reliable organizations Define barriers to embracing a culture of safety Discuss medication error causes and reporting Identify tools and strategies to prevent harm
6 Overview of Infirmary Health Largest non governmental healthcare system in the state and the second largest not for profit healthcare system in Alabama Serves an 11 county area of south AL and north Escambia County, FL 5 acute care hospitals (> 900 beds) 2 post acute care facilities Physician clinic network with more than 30 locations, three diagnostic centers, three urgent care clinics and other affiliates. 700 active physicians and more than 5,000 employees Care for over 800,000 patients annually Contributes nearly $1.8 million annually to local programs and agencies, through corporate gifts and sponsorships, employee volunteerism and uncompensated medical care.
7 Infirmary Health Awards and Recognitions Mobile Infirmary Medical Center Bariatric Center named a Center of Excellence Diabetes Center s education program recognized by the American Diabetes Association Q Medmined Surveillance System report- MI was ranked Excellent among state and national hospitals for infection prevention performance for the 8th consecutive quarter Q National Health Care Safety Network (NHSN) report- MI was ranked better than most hospitals in 2 areas: Central Line Related Associated bloodstream Infections (CLABSI) MI was ranked in the top 10 hospitals in the state with lower CLABSI rates. Surgical Site Infections for Colon Surgery (SSI) MI was ranked in the top 5 hospitals in the state with lower Colon SSI rates. Silver level award from American Stroke Association/ Get with the Guidelines for performance in Stroke Care Measures Blue Distinction Center for Knee and Hip Replacement Blue Distinction Center for Spine Surgery MI s pre op prep process for CABG surgery was highlighted by Joint Commission as a Best Practice for Surgical Site Infection Prevention. MI s Fall Reduction Hospital Engagement Network (HEN) Project was featured as a Best Practice in the VHA-SE Bright Ideas Journal segment. MI GI Lab successfully met the requirements to be recognized as a unit that promotes quality in endoscopy through the American Society of Gastrointestinal Endoscopy (ASGE) Unit Recognition Program (EURP). Gold Astor Award Women s Services Creative Campaign Gold Astor Award for the North Baldwin Infirmary birth center virtual tour Thomas Hospital HealthGrades Outstanding Patient Experience Award 2013 top 15% nationally Employee Opinion Survey 85th percentile nationally Blue Distinction Knee & Hip Replacement Surgery Women scertified Awards for Best Patient Experience, Obstetrics, Heart and Orthopedics VHA Recognition for Venous thromboembolism project
8 Safety Story
9 Safety Story
10 What is Safety Culture? Safety culture is the sum of what an organization is and does in the pursuit of safety. The Patient Safety (PS) chapter of the TJC accreditation manuals defines safety culture as the product of individual and group beliefs, values, attitudes, perceptions, competencies, and patters of behavior that determine the organization s commitment to quality & safety.
11 How would you describe your organization s safety culture?
12 Harm in Healthcare A 747 per Day Every Day 1999 IOM report: To Err is Human: Building a Safer Health System Estimates 44,000 to 98,000 Americans die annually from medical errors. To Err is Human, Institute of Medicine (1999) James estimates 210,000 to 440,000 patients, each year, suffer from preventable harm that contributes to their death. James, John, A New Evidence based Estimate of Patient Harms Journal of Patient Safety, September 2013, Volume 9, Issue 3 That s makes Death from Medical Errors the 3 rd leading cause of death (CDC 2013) 210,000/365 = 575 people/day (#1 747) 440,000/365 = 1,206 people/day (#2 747) 12
13 Just How Dangerous is Health Care? 13
14 High Risk Situations in Healthcare 14
15 Characteristics of Highly Reliable Organizations? Make safety their number one priority at all times It means getting things right EACH and EVERY time Avoid catastrophes in environments where normal accidents can be expected Focus improvement efforts on process improvements over seeking, blaming, & disciplining individuals (Just Culture)
16 Highly Reliable Industries Air Traffic Controller Space Program Operations Chemical Plant Operations Nuclear Power Plant Military Operations Center Aircraft Carrier, Flight Deck Operations 16
17 What is the ultimate goal of a safety focused or highly reliable organization? ZERO events of harm Does this mean ZERO events?
18 How Do We Achieve our GOAL: ZERO Events of Harm? 100% Awareness Event Rate Skill Acquisition Habit Formation 20% Performance Time 18
19 Serious Safety Event Rate (SSER) vs. Total Reported Med Variances (TRMV) 1.50 Serious Safety Event Rate (SSER) vs Total Reported Med Variances (TRMV) Infirmary Health, January 2015 March 2017 (27 months) Serious Safety Event Rate (SSER) Total Reported Med Variances (TRMV) Total Reported Med Variances SSER
20 Serious Safety Event Rate (SSER) vs. Total System Wide Incident Reports (SWIR) 1.50 Serious Safety Event Rate (SSER) vs Total System Wide Incident Reports (SWIR) Infirmary Health, January 2015 March 2017 (27 months) Serious Safety Event Rate (SSER) Total System Wide Incident Reports (SWIR) Total System Wide Incidents SSER
21 Barriers to Establishing Safety Culture
22 Understanding Cultural Challenges to Safety 1. Senior leadership support is absolutely paramount! 2. Senior leadership support is absolutely paramount! All leaders must be on board, be all in & fully supportive, and speak the safety language. 3. Front line staff (sharp end) need to understand the why the organization is embarking on this safety journey. 4. Consistent feedback to staff is crucial to explain the why & check in with how am I doing? 5. Not as easy as flipping a switch, any culture change takes time, practice, & reinforcement
23 TJC Sentinel event #57, March 1, 2017
24 Medication Errors
25 ISMP & NCCMERP definition Medication Error/ Variance is defined as: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.
26 ISMP & NCCMERP definition Medication Error/ Variance is defined as: A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labeling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use.
27 National Coordinating Council on Medication Error Reporting (NCC MERP) Categories of Medication Errors
28 Assessment Question: At what harm category (letter) does an error reach patient? C
29 Assessment Question: At what harm category (letter) does an error begin to cause harm? E
30 How Do Errors Happen? Sometimes an error occurs, but an event or injury is prevented by an internal system of checks Significant events or injuries Sometimes multiple errors line up to allow a significant event or injury to occur Root cause analysis (RCA) generally initiated for any potential Serious Safety Event (SSE)
31 Three Ways Humans Perform Skill Based Performance (Auto Pilot Mode) 3 in 1000 acts will be performed in error Rule Based Performance (If-Then-Response Mode) 1 in 100 performed in error Knowledge Based Performance (Figuring-It-Out Mode) 3 of 10 choices performed in error 31
32 How does Infirmary Health Foster a Culture of Safety?
33 Practices Encouraging Safety High Reliability Infirmary Health Safety/Reliability Program consists of: Error Prevention Toolkit Hospital Huddles Unit Based Daily huddles Patient Safety Coaches Rounding to influence safety behaviors Serious Safety Event Committee Serious Safety Event Graphs Root Cause Analysis Safety Leadership Team top 3 Recognition Program Lifeguard award/pin & Safety Hero 33
34 Practices Encouraging High Reliability Infirmary Health Safety/Reliability Program consists of: Error Prevention Toolkit Hospital Huddles Unit Based Daily huddles Patient Safety Coaches Rounding to influence safety behaviors Serious Safety Event Committee Serious Safety Event Graphs Root Cause Analysis Safety Leadership Team top 3 Recognition Program Lifeguard award/pin & Safety Hero 34
35 Error Prevention Tool Kit 35
36 Practices Encouraging High Reliability Infirmary Health Safety/Reliability Program consists of: Error Prevention Toolkit Hospital Huddles Unit Based Daily huddles Patient Safety Coaches Rounding to influence safety behaviors Serious Safety Event Committee Serious Safety Event Graphs Root Cause Analysis Safety Leadership Team top 3 Recognition Program Lifeguard award/pin & Safety Hero 36
37 Daily Safety Huddles 37
38 Practices Encouraging High Reliability Infirmary Health Safety/Reliability Program consists of: Error Prevention Toolkit Hospital Huddles Unit Based Daily huddles Patient Safety Coaches Rounding to influence safety behaviors Serious Safety Event Committee Serious Safety Event Graphs Root Cause Analysis Safety Leadership Team top 3 Recognition Program Lifeguard award/pin & Safety Hero 38
39 Practices Encouraging High Reliability Infirmary Health Safety/Reliability Program consists of: Error Prevention Toolkit Hospital Huddles Unit Based Daily huddles Patient Safety Coaches Rounding to influence safety behaviors Serious Safety Event Committee Serious Safety Event Graphs Root Cause Analysis Safety Leadership Team top 3 Recognition Program Lifeguard award/pin & Safety Hero 39
40 Safety Heroes
41 Error Prevention Tool Kit 41
42 3 Way Repeat Backs When information is transferred...use 3-Way Communication! 1 Sender initiates communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear and concise format. 2 Receiver acknowledges receipt by a repeat back of the order, request, or information. 3 Train our ears to listen for That s Correct! it s a codeword for we understand each other Sender acknowledges the accuracy of the repeat back by saying, That s correct! If not correct, Sender repeats the communication. A Safety Phrase: Let me repeat that back
43 Importance of 3 Way Readback
44 Error Prevention Tool Kit 44
45 Importance of Cross Check Individual reliability is limited: 1 defect per 1,000 opportunities Peer Checking multiplies the error probability: x = 1 defect per million
46 What Does Bad Cross Checking look like? 46
47 Summary Discussed the culture of safety Described characteristics of highly reliable organizations Defined barriers to embracing a culture of safety Discussed medication error causes and reporting Identified tools and strategies to prevent harm
48 Questions? Trey Gwin can be reached at and you can learn more about Infirmary
49 Relevant Definitions Harm: Impairment of the physical, emotional, or psychological function or structure of the body and pain or injury resulting therefrom. (NCCMERP) Adverse Drug Event (ADE): An injury resulting from medical intervention related to a drug. Source: Institute of Medicine (IOM) Medication Error (ME): A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Source: (NCC MERP). Adverse Drug Reaction (ADR): Any response to a drug which is noxious and unintended which occurs at doses normally used in man for prophylaxis, diagnosis, or therapy of disease, or for the modifications of physiological function. Source: World Health Organization (WHO)
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