Presentation to the Maryland Patient Safety Center 14 th Annual Patient Safety Conference, Baltimore, Maryland Rosemary Gibson, Author, Wall of

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1 Presentation to the Maryland Patient Safety Center 14 th Annual Patient Safety Conference, Baltimore, Maryland Rosemary Gibson, Author, Wall of Silence Senior Advisor, The Hastings Center April 13, 2018

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4 How Far We Have Come

5 How many of you believe people are alive today because of improvements in patient safety?

6 What do YOU think are the biggest accomplishments in patient safety? Take a Few Minutes to Talk With Someone Seated Next To You

7 GAMECHANGERS

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9 CONCLUSIONS An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period. In other words..infections are NOT inevitable!

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11 ANOTHER GAMECHANGER

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13 What have YOU done that YOU are most proud of that has made care safer? Take a Few Minutes to Talk With Someone Seated Next To You

14 This is the same hospital where my father died from a medical error. I was not impressed with things back then and I have many bad memories. But ten years later we are here again. I am seeing many positive changes in safety culture and patient-centered practice. This reminds me of all the work we have done every day to make care safe. Collectively, we do make a huge difference in saving peoples lives. Daughter, wife, university researcher, state medical board public member, patient safety advocate

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17 The Journey to Just Culture

18 Annie s Story and Just Culture

19 Patient: I feel my glucose is really high. Tech and RN read the glucometer and interpreted it as reading the patient had critically high blood glucose Here is what they saw.

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21 The patient was given repeated doses of insulin. The patient s condition deteriorated and rapid response was called. Patient was transferred to the ICU and given multiple doses of glucose

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24 1. A hospital-level customization with a pop-up text message covered a critical reading. 2. The glucometer was poorly designed and allowed a pop-up text message to cover up essential information

25 What was the impact on Annie of a lack of just culture?

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27 It s All About Culture

28 Speaking Up: If You See Something Unsafe Say Something (and Why We Don t)

29 Audience Response System On your phone, go to:

30 Question 1: Do your colleagues speak up if they see something unsafe? Answer choices 1. Always 2. Sometimes 3. Rarely

31 Question 2: Do you speak up if you see something unsafe? Answer choices 1. Always 2. Sometimes 3. Rarely

32 Drive out fear so everyone can work effectively. Deming

33 Do you think a department or hospital where staff feel safe speaking up has better patient outcomes?

34 Data show a correlation between a culture where staff feel safe speaking up and patient outcomes Thanks to Dr. Michael Leonard

35 No BSI = 5 months or more w/ zero No BSI 21% No BSI 31% No BSI 44% The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care Attribution Bryan Sexton

36 CULTURE IS RELATED TO Teamwork Climate Scores Across Facility HCAHPS Medication Errors per Month Days between C Diff Infections Illustrative Data: Extracted from Blinded Client Data Source: Dr. Michael Leonard Days between Stage 3 Pressure Ulcers 18 52

37 AND UNFAVORABLE EMPLOYEE OUTCOMES Teamwork Climate Scores Across Facility <60% Score = Danger Zone Employee Satisfaction Employee Injury per 1000 days Employee Absenteeism per 1000 days RN Vacancy Rate 9 1 Illustrative Data: Extracted from Blinded Client Data

38 What Commitment Will You Make To Continue On The Safety Journey Especially on Open and Honest Communication? Take a Few Minutes to Talk With Someone Seated Next To You

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40 An Invitation! Help The Next Generation Become Committed to Patient Safety

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42 The Telluride Patient Safety Summer Camp 4-day interprofessional summer immersion program in patient safety Faculty are nationally-recognized patient safety leaders

43 Cost to medical and nursing students: $0 3 locations each summer: Colorado, Napa, California, Washington, D.C. suburbs

44 This summer I had the amazing opportunity to attend a safety camp in Telluride, Colorado. Med students, nursing students, doctors and nurses from around the country were able to gather together in Telluride to expand our knowledge on patient safety. We spent the week discussing patient safety improvement, techniques, philosophy and approaches for reducing patient injury and adverse outcomes

45 It was an eye-opening week for me and I learned so much. The sense of empowerment I felt after the conference was incredible. Telluride truly has been the highlight of my nursing career thus far. Brennan Killeen, RN, BSN, Clinical Nurse at MedStar Georgetown University Hospital Telluride Scholar June 2015

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50 To Learn More and Apply: Google Telluride Patient Safety

51 In closing

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53 A moment to remember the gift

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