TIME OUT! A Patient Safety Strategy. Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service

Transcription

1 TIME OUT! A Patient Safety Strategy Col Doug Risk, Lt Col Kelli Mack USAF Dental Evaluations & Consultation Service

2 Disclosures The opinions expressed in this presentation are those of the authors and do not necessarily reflect the official position of the US Air Force (USAF) or the Department of Defense (DoD). Devices or materials appearing in this presentation are used as examples of products and technologies and do not imply an endorsement by the authors, the USAF or the DoD. The presenters have no financial interest to disclose

3 Objectives Explain systems thinking and mistake proofing principles Describe The Joint Commission's (TJC) Tools for reducing harm and improving patient safety (e.g. National Patient Safety Goals (NPSG), Universal Protocol) Identify key elements of an effective Time-Out

4 Overview Patient Safety Basics Trusted Care and High Reliability Orgs (HROs) Review of Air Force Root Cause Analyses AFDS System Redesigning TeamSTEPPS approach Team Huddles Time Out Who, What, Where

5 What is patient Safety A SYSTEMS approach to reducing harm Process centric, not person centric How will we achieve zero harm Patient Safety Embrace ideals of HROsand make them our own Build a reliable system 9 Principles of Trusted Care

6 What Is Patient Safety? SYSTEMS THINKING: acknowledges that humans make errors Robert M. Wachter, MD, Understanding Patient Safety REDESIGN THE SYSTEM: to prevent & catch errors before they occur James Reason s Swiss Cheese model

7 High Reliability Organizations 1: Preoccupation with Failure To avoid failure, we must look for it Must be sensitive to early signs of failure 2: Reluctance to simplify interpretations Labeling and clichés are harmful (e.g. another needles stick) Must investigate every failure 3: Sensitivity to Operations Systems are not static Every system has a relationship with every other system 4: Commitment to Resilience Must maintain function during high stress events Must learn and bounce back from untoward events 5: Deference to Expertise Primary provider opinion is important but is not the only opinion Lowest level of participant has equal voice as to input into a process

8 9 Principles of Trusted Care

9 A Reliable System - Trusted Care Why principles? Principle-based behavior yields predictable outcomes Behavior linked to a principle is predictable Shared collective mindfulness to a set of principlebased behaviors can lead to a culture that sees safety as the priority and achieves safe results Why do HROshave principles? Aviation, nuclear power, and healthcare HROsadopt a set of principles to guide their work at every level of the organization.

10 A Reliable System - Trusted Care How do principles drive behavior? behavior yields results (good or bad) Individuals need to know how they should behave How the work contributes to the mission. Principles set the standards for desired and acceptable behavior.

11 Building A Reliable System? Well-defined workflows Team briefs, huddles, Time-Outs Error proofing principles Checklists, improve transparency, redundancies for errorprone activities, reduce interruptions, communication Create a culture of safety Awareness of high risk activities, leadership commitment, error reporting without fear of reprisal, willingness to identify errors and create solutions, discuss solutions Measurement strategies Design/sustain systems with constant assessment of process

12 TJC NPSG2016 The Joint Commission (TJC) 2016 National Patient Safety Goals (NPSGs) 1. Improve the accuracy of patient identification 3. Improve the safety of using medications 7. Reduce risk of HAIs Prevent Mistakes in Surgery

13 Pt ID: 2 identifiers right patient gets the right blood product Medication Safety Label medicines, syringes, cups, basins Take extra care with pts on blood thinners Prevent infection TJC Goals Hand hygiene, set goals for improving handwashing Use proven guidelines to prevent post surgical infections

14 TJC Universal Protocol Joint Commission has National Pt Safety Goals Wrong Site Pre-procedure verification Mark site Perform a time-out

15 2013 RCA Findings Most frequently reported contributing factors Ineffective/No team brief/huddle (TeamSTEPPS) Ineffective use of the UP (including Time-Out) Most frequently reported contributing factor related to the Time-Out Site verification/re-verification Do TeamSTEPPS (briefs, huddles, handoffs, code words) AFDS Universal Protocol for all procedures Team approach/ provider & tech when appropriate Verify Who, What, Where When verifying who must be looking at a reference (i.e. the chart)

16 Learn From Others Brandon Mull Author of the FablehavenFantasy Series States: Smart People Learn from their Mistakes, but the Real Sharp Ones Learn from the Mistakes of Others. One Way to Learn is to Have Visibility of Events that Have Occurred in our DTF s.

17 2014 Checklist AFSO21 The old Time-Out checklist was scrutinized Revealed non-compliance Result Lengthy/too wordy Confusing/too complex Personnel felt insufficiently trained Creation of a simplified Time-Out TJC Time-Out used as a guide AFDS: WHO WHAT WHERE

18 Re-Verify After Interruptions The AFDS Time-Out

19 Situation Monitoring Following Info is from TeamSTEPPS Situation monitoring: process of actively scanning & assessing a situation to gain information and maintain an accurate understanding of the situation This is a skill and can be learned Situation awareness: know your surroundings A detailed picture of the situation. Must continually assess because situations are dynamic

20 Team Brief Patient safety starts prior to patient appointment Identify right chart, materials available Medical history Blood pressure prior to procedure Inhaler, nitroglycerine, blood sugar Medication or pre-medication (oral sedation) Possible pitfalls discussed ahead of time

21 AFDS Time-Out Team re-confirms PATIENT IDENTITY (WHO) Verbal communication & agreement Team re-confirms PROCEDURE (WHAT) Verbal communication & agreement Team re-confirms the SITE (WHERE) Verbal communication & agreement Accomplish this by counting teeth or using anatomy landmarks (look in the mouth)

22 After The AFDS Time-Out Continually re-verify site When working on multiple teeth Prior to initiating procedure on a new tooth/site, the dental Team will re-verify the site and procedure If an interruption occurs (should be minimized) Team will re-verify the site and procedure Utilize code words when needed

23 Continuous Learning 2013 Meta Analysis 94% noncompliance with old checklist Ineffective/No team briefs, huddles, Time - Outs 2014 Checklist AFSO21 Wordy, confusing checklist 2015 Instrument Processing AFSO21/FMEA Revealed many system errors 2015 instrument processing 8 step continuous process improvement Standardized training is vague Many processes/too much variation

24 Root Cause Analysis (RCA) A process for identifying the basic (causal) factors A systematic event investigation Proper outcomes of RCAs Leads to learning Countermeasure development (think system improvements) Leads to behavior changes When involved in an RCA ask What practices are in place allowing such events to occur? What can prevent/catch errors leading to such events? How can the process be standardized? How can better behaviors be adopted?

25 Motivating For Change Multilevel involvement Senior leadership Mid level management Frontline personnel Positive encouragement/reinforcement Walking/talking/showing/being Involved Acknowledge accomplishments: good catches, system redesign, safety reporting for learning/improvement Create an environment of safety and respect Facilitate teamwork and collaboration Stay Clinical!

26 QUESTIONS??? Death: Dead at time of Assessment Harm Severe Harm: Bodily or psychological injury (including pain or disfigurement) that interferes significantly with functional ability or quality of life Moderate Harm: Bodily or psychological injury adversely affecting functional ability or quality of life, but not as the level of severe harm Mild Harm: Bodily or psychological injury resulting in minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and or/increased length of stay No Harm No Harm: Event reached patient, but no harm was evident Near Miss: Event occurred but did not reach patient NEAR MISS Unsafe Condition: Potential event, any circumstances that increase the probability of a patient safety event For Official Use Only. All information is subject to the Privacy Act of 1974, 5 USC 552 and 10 USC /25/2016