SafeStart & Patient Safety
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1 SafeStart & Patient Safety NS Safety Council Conference Halifax NS March 23, 2006 Allison Townsend, Electrolab Training Systems Belleville ON
2 Electrolab Training Systems Belleville ON 30 Years
3 Brief review of current Patient Safety Initiatives & a look at SafeStart Healthcare focusing on the Human Side of Safety
4 Why Patient Safety? Identified as an issue in the report To Err is Human, 1999 Canadian Adverse Events Study by Baker & Norton, 2004 These studies and others in Australia & the UK evaluated incidents affecting healthcare consumers Healthcare is an extremely complex, ever-changing process and sometimes patients are inadvertently harmed
5 Traditional Culture in many organizations Blaming and shaming Previously when an incident occurred: tendency had been to Hide & Blame Healthcare workers were expected to be perfect, different from the rest of society This focus denies the reality that making errors and mistakes is the process by which we learn
6 Steps to protecting Patient Safety Focus on improving systems Development of alarms and other devices to prevent errors Executive Walk Arounds Site Marking & Time-outs prior to surgical procedures Safer Healthcare Now 6 initiatives
7 Safer Healthcare Now! AMI: Improve care for Acute Myocardial Infarctions CLI: Prevent Central Line Infections MedRec: Prevent Adverse Drug Events with Drug Reconciliation Rapid Response Teams SSI: Prevention of Surgical-Site Infections VAP: Prevention of Ventilator-Associated Pneumonia
8 more Patient Safety Initiatives Computerized Physician Order Entry System Encouraging a non-punitive environment Independent Double-Check Safe-Catch/Near-Miss Reporting Dedicated Nurse for Medication-Dispensing Training on Root Cause Analysis FMEA: Failure Mode & Effects Analysis Focus on Open Disclosure Policies/Training others
9 Increased focus on Employee Training Front-line workers benefit from additional support and training so they can respond effectively to stresses in the healthcare environment Trying to be careful is not enough Employees need tools to prevent errors
10 SafeStart Healthcare: Uses the proven SafeStart techniques for error-reduction Teaches employees how to prevent errors in the healthcare environment, where systems have not been or can not be put in place to eliminate errors Focus on Learn & Prevent
11 SafeStart Advanced Awareness Training Written 7 years ago by Electrolab VP: Larry Wilson Designed to improve Employee Safety in Industrial, Petro-Chemical & Manufacturing Sectors Teaches workers error-reduction techniques Increases employee buy-in to Safety Culture Improves Over one million people trained, in 8 languages
12 Original SafeStart Teaches Employees how to reduce errors Reduces personal injuries Works on-the-job and off-the-job Used successfully to reduce employee injuries in these Canadian Healthcare facilities: Nipigon Regional Hospital, ON Five Hills Health Region, Moose Jaw, SK Saskatoon Regional Health Authority, implementation in process, started Oct. 2005
13 Goals of SafeStart Healthcare Bring Patient Safety to the next level Prevent incidents that impact on patients Help people improve their own personal safety and reduce injuries Improve teamwork & communication Empower people to bring forward concerns and report near-misses Give people real tools they can use everyday
14 SafeStart Healthcare Training Address Human Factors Provide a new avenue to prevent Medical errors and Patient Injuries Lower costs to healthcare organizations by improving quality and employee health & safety
15 SafeStart Healthcare Uses a variety of situations we can relate to, to show the relationship between our state of mind, and errors that occur
16 Stop Sign
17 Sources of Unexpected Self - own actions cause or contribute to incident/injury. Other People - someone else s behavior causes or contributes to incident/injury. Events - something unexpected happens without you or someone else involved (e.g. machine or alarm malfunctions; traffic lights start working incorrectly; coupling fails; hose bursts; etc.)
18 States cause errors
19 SafeStart Teaches participants How errors occur How to control behaviours that lead to errors Think about habits Analyze close calls, near misses
20 SafeStart Healthcare Designed to have Universal Application Blend with other initiatives Work for all departments Provide a Common Language Change the way people - Think - Respond
21 A Culture of Safety Focuses primarily on the person Empowers & encourages ownership Teaches We are in control of our responses to situations Provides techniques to do this
22 SafeStart uses Personal Situations / Reflective Learning Close Call analysis Self triggering Techniques Storytelling Content over time Improving habits Observing Coaching each other
23 SafeStart Healthcare Facilitator lead Participant exercises Observation of self & others Five Units / Five Weekly Sessions 1½ - 2 Hour Sessions Video Scenarios: 60% Patient Safety 40%: Employee Safety, On-the-Job; Off-the-job; Loss to Facility
24 Typical Training Session Table Group Discussions Lecture Workbook exercises Real-life situations / Story-telling Sharing of peer & self-observations since last meeting Interactive exercises Video scenarios combination of work & non-work scenes Chance to reflect on concepts before next training session
25 SafeStart Train the Trainer 2 days of Training with SafeStart Consultant 4 sets of Training Materials: Leader s Guides - 6-part package includes Power Point Presentation Videos - 5 tapes or DVDs Employee workbooks - set of 5, 1 per unit One set required for each employee Management sessions are also available
26 SafeStart Healthcare Leader s Guide Set of five complete Guides Successful Facilitation Guide Speaker Notes Interactive Group Exercises Power Point Slides Posters in PDF format
27 SafeStart Healthcare Employee Materials Set of Five Workbooks per Student SafeStart Definition Card Critical Error Reduction Technique Card Pad of Observation Cards Completion Certificate Optional Take Home Package
28 Implementation Plan Collect Data Prior to Training: Patient Safety/Incident Statistics Employee Accident Statistics Employee Survey; Cultural Assessment After 3 months: Review above data plus Employee Post-Test SafeStart Observation cards Compare results
29 Which Departments? Focus on areas where risk is greater Don t select a unit where there are numerous issues at present that might challenge the success of the process Train complete nursing units so team members can support each other, using Common Language
30 Beta Sites St. Elizabeth Health Center, Youngstown, Ohio (550 beds) Athens-Limestone Hospital, Athens, Alabama (101 beds) Medical City Dallas/North Texas Hospital for Children, Dallas, Texas (598 beds) Cabell Huntington Hospital, Huntington, West Virginia (300 beds) Baylor Medical Center, Grapevine, Texas (100 beds)
31 Case Study #1 150-bed facility: laboratory Results 40% reduction in errors attributed to human errors 27% total decline in incidents Improved discussions related to patient safety issues Positive change in culture reported
32 Case Study #2 Athens Limestone Hospital 100-bed facility Implemented throughout facility Employees felt more keenly aware of safety issues Promoted better teamwork Gave them control over daily situations Reduced Lost Time Accidents to zero
33 Implementing SafeStart The Benefits Increase Close Call/Near Miss Reporting Decrease Major Incidents Create a Culture of Safety Develop a Sense of Team Lower Employee Injuries: on-the job, off-the-job and thereby reduce costs from staffing issues and compensation claims Reduce Loss to the organization
34 What are people saying SafeStart Healthcare isn t a new policy, procedure or process, it s a state of mind. A new way of thinking. SafeStart Healthcare allows us to demonstrate to our employees that we care about their own safety. SafeStart Healthcare encourages employees to actively think about habits that may cause errors to occur. SafeStart Healthcare focuses on individual awareness and control. This program empowers employees to take responsibility for their own safety and that of their patients.
35 SafeStart Healthcare Creating an atmosphere where Safety is a habit
36 Questions
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