Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM
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1 Patient Safety is Everyone s Responsibility Tammy Brock, MSN RN CPHRM Objectives Know TJC 2016 National Patient Safety Goals Discuss human factors on patient safety What is your role in patient safety? Why do we need to report safety issues?? 1
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3 High-Reliability Organization Preoccupation with Failure EVERYONE is focused on errors and near misses Attention to detail How to prevent errors from happening again Finding and fixing problems is supported by leadership 3
4 Reluctance to Simplify WHY, WHY, WHY Root Cause Analysis Think outside the box Bring in front line staff Provide all of the necessary training Standardization Sensitivity of Operations Situation Awareness What is the potential for harm FMEA Pay attention and speak up Deference to Expertise People closet to the work are the most knowledgeable about the work- Kaizen events Senior leader/manager rounding Share concerns hierarchy Provide feedback 4
5 Commitment to Resilience Assume the system is at risk to fail Immediately respond and minimize the harm Practice, practice, practice Cross monitor each other Human Factors of Patient Safety We are HUMAN! We are not perfect. 5
6 D1 D2 Identify Contributing System Factors I1 I2 Adapted from James Reason s Decision Tree for Determining the Culpability of Unsafe Acts and the Incident Decision Tree of the National Patient Safety Agency (United Kingdom National Health Service) Identify Contributing System Factors C1 C2 C3 C4 Identify Contributing System Factors S1 S2 Identify Contributing System Factors 11/10/2016 How to overcome the imperfection Checklists Standardize processes and eliminate steps Knowledge and training If you see something, say something! Examine close calls and near misses. Perform FMEAs Be more Proactive instead of Reactive. Adopt best practices. Make patients active participants in their own care. Separate process issues from people issues. Start Performance Management Decision Guide Deliberate Act Test Incapacity Test Compliance Test Substitution Test Did the individual intend the act? Is there evidence of ill health or substance abuse? Did the individual depart from policies, procedures, protocols, or generally accepted performance expectations? Would individuals in the same profession and with comparable knowledge, skills, and experience act the same under similar circumstances? Were the policies, procedures, protocols, or performance expectations available, understandable, workable, and in routine use? Did the individual act with malicious intent (i.e. to cause individual harm or other damage)? Did the individual have a known medical condition? Is there evidence that the individual chose to take an unacceptable risk OR has a trend in poor performance or decision making? Were there deficiencies in related training, experience, or supervision? Were there significant mitigating circumstances? Malevolent or Willful Misconduct Medical Condition and/or Substance Abuse Possible Reckless or Negligent Behavior Possible Unintended Human Error Possible System Induced Error (Consult Human Resources) Disciplinary action Report to professional group or regulatory body Law enforcement referral (Consult Human Resources) Occupational health referral Adjustment of duties Leave of absence If substance abuse: Substance abuse testing Disciplinary action (Consult Human Resources) Disciplinary action Job-fit consideration (Consult Human Resources) Console Coaching Mentor assignment Increased supervision Performance improvement plan Adjustment of duties Console and/or Coach the Individual AND Find & Fix Process Problems Revision 3, April Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED National Patient Safety Goals Joint Commission 6
7 Background The National Patient Safety Goals (NPSGs) were established in 2002 to help accredited organizations address specific areas of concern in regards to patient safety The first set of NPSGs was effective January 1, 2003 The Patient Safety Advisory Group advises The Joint Commission on the development and updating of NPSGs Patient Safety Advisory Group Panel of widely recognized patient safety experts Nurses, physicians, pharmacists, risk managers, clinical engineers, other professionals Hands-on experience in addressing patient safety issues in wide variety of health care settings Advises The Joint Commission how to address emerging patient safety issues NPSGs, Sentinel Event Alerts, standards and survey processes, performance measures, educational materials, Center for Transforming Healthcare projects Patient Identification Goal 1: Improve the accuracy of patient identification. NPSG : Use at least two patient identifiers when providing care, treatment and services. NPSG : Eliminate transfusion errors related to patient misidentification. 7
8 Improve Communication Goal 2: Improve the effectiveness of communication among caregivers. NPSG : Report critical results of tests and diagnostic procedures on a timely basis. Goal 3: Medication Safety Improve the safety of using medications. NPSG : Label all medications, medication containers, and other solutions on and off the sterile field in perioperative and other procedural settings. NPSG : Reduce the likelihood of patient harm associated with the use of anticoagulant therapy. NPSG : Maintain and communicate accurate patient medication information. 8
9 Clinical Alarm Safety Goal 6: Reduce the harm associated with clinical alarm systems. NPSG : Improve the safety of clinical alarm systems. Leaders establish alarm safety as a hospital priority Identify the most important alarm signals Establish policies and procedures for managing alarms Clinically appropriate alarms When alarm signals can be disabled Who can set parameters, change parameters, turn off parameters Monitoring and responding to alarm signals. Educate staff and LIP Goal 7: Health Care-Associated Infections Reduce the risk of health care-associated infections. NPSG : Implement evidence-based practices to prevent central line-associated bloodstream infections. NPSG : Implement evidence-based practices to prevent health care-associated infections due to multidrug-resistant organisms in acute care hospitals. NPSG : Implement evidence-based practices for preventing surgical site infections. NPSG : Implement evidence-based practices to prevent indwelling catheterassociated urinary tract infections (CAUTI). 9
10 Reduce Falls Goal 9: Reduce the risk of patient harm resulting from falls. NPSG : Reduce the risk of falls. Pressure Ulcers Goal 14: Prevent health care-associated pressure ulcers (decubitus ulcers). NPSG : Assess and periodically reassess each resident s risk for developing a pressure ulcer and take action to address any identified risks. Goal 15: Risk Assessment The organization identifies safety risks inherent in its patient population. NPSG : Identify patients at risk for suicide. (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.) NPSG : Identify risks associated with home oxygen therapy, such as home fires. Applies to: Home Care 10
11 Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery UP : Conduct a preprocedure verification process. UP : Mark the procedure site. UP : A time-out is performed before the procedure. What is Your Role in Patient Safety?? Engage and Educate the patient Speak up. Educate yourself. Adopt best practices. Model professional behavior. Eliminate intimidating behavior. Seek out safety issues. Hold each other accountable! When you see it, you own it. Thank you!! 11
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