Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD

Presented by: Suchita Pancholi, MD Letitia Cameron, MD Aniel Rao, MD Michael Hill, MD

I. Introductions II. III. IV. Marshmallow Challenge Why Teach Patient Safety? Barriers to Teaching Patient Safety V. Components of a Patient Safety Curriculum (ex. Goals, RCA) VI. Questions & Comments Patient Safety is Not a Gadget, but a State of Mind: Implementing a Patient Safety Education Curriculum

Describe common causes of medical errors Identify potential barriers to learning and teaching a patient safety curriculum Define the components of a patient safety curriculum Practice a mock root cause analysis

THE MARSHMALLOW CHALLENGE Goal: Develop skills to improve effective communication and teamwork Task: Work as a team to build the tallest tower with only the resources given at each table Resources: 20 Spaghetti sticks, 1 yard of tape, 1 yard of string, 1 large marshmallow. Rules: Can only use the materials provided and must be attached to the flat surface of table. Measurement will be from table to the marshmallow. The entire marshmallow must be on top. *Must be free-standing at 8 mins. **Tower RECORD 33

KEY POINTS Main teaching point- Pool Your Supplies & Brains Well Defined Roles Be Resourceful Promote Creativity Build Trust Teamwork through Communication Leadership

https://snyderfamilyhistory.files.wordpress.com/2013/05/2011-4-3-pentagon-arlington-tgr_118e.jpg

Medical Error

Loss of human life >400,000 deaths annually Patient harm 10-20 fold that of annual deaths Estimated cost to the nation $1 trillion! Effect on families Loss of trust in physicians and the healthcare system Decreased satisfaction by healthcare providers

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Errors Medical Decision-Making Errors Treatment Errors Medication Errors Procedural Complications Faulty Communication Inadequate Supervision Leape, LL et al. The nature of adverse in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324:377-384

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Errors Delayed diagnosis Wrong diagnosis Medical Decision-Making Errors Treatment Errors Medication Errors Procedural Complications Faulty Communication Inadequate Supervision

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Errors Medical Decision-Making Errors Cognitive Biases Treatment Errors Medication Errors Procedural Complications Faulty Communication Inadequate Supervision

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Errors Medical Decision-Making Errors Treatment Errors Wrong treatment Inappropriate treatment Delayed treatment Medication Errors Procedural Complications Faulty Communication Inadequate Supervision

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Errors Medical Decision-Making Errors Treatment Errors Medication Errors Medication duplications Medication reconciliation errors Inappropriate medication Procedural Complications Faulty Communication Inadequate Supervision

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Errors Medical Decision-Making Errors Treatment Errors Medication Errors Procedural Complications Short cuts Wrong site Poor sterile technique Faulty Communication Inadequate Supervision

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Errors Medical Decision-Making Errors Treatment Errors Medication Errors Procedural Complications Faulty Communication

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Medical Decision-Making Treatment Medication Procedural Complications Faulty Communication Reliance on EHR Poor handwriting Incomplete communication Lack of communication Inadequate Supervision

COMMON TYPES of MEDICAL ERRORS Diagnosis or Evaluation Medical Decision-Making Treatment Medication Procedural Complications Faulty Communication Inadequate Supervision Interns gone wild Reliance on upper level residents Assumption that residents ask for help when they need it

COMMON CAUSES of MEDICAL ERRORS Ignorance Inexperience Faulty Judgment Fatigue & Job Overload Failure to Monitor System Flaws Lack of Leadership Electronic Health Records Increasing Complexity of Medicine

COMMON CAUSES of MEDICAL ERRORS Ignorance Not as bad as they say I m a doctor I know how to keep my patients safe No Harm No Foul mentality Inexperience Faulty Judgment

COMMON CAUSES of MEDICAL ERRORS Ignorance Inexperience New intern syndrome New attending syndrome Faulty Judgment

WE DID THIS? I GUESS WE HAVE NO CHOICE BUT TO OPERATE? NO. WAIT AND HOPE THINGS IMPROVE.

COMMON CAUSES of MEDICAL ERRORS Ignorance Inexperience Faulty Judgment Fatigue & Job Overload 80 hour weeks Multiple roles and responsibilities Intern syndrome Failure to Monitor System Flaws Lack of Leadership Electronic Health Records Increasing Complexity of Medicine

COMMON CAUSES of MEDICAL ERRORS Ignorance Inexperience Faulty Judgment Fatigue & Job Overload Failure to Monitor/Lack of Leadership Lack of emphasis on the importance of patient safety Disengaged leadership Interns gone wild System Flaws Lack of Leadership Electronic Health Records Increasing Complexity of Medicine

Ignorance Inexperience Faulty Judgment Fatigue & Job Overload Failure to Monitor System Flaws COMMON CAUSES of MEDICAL ERRORS Poor staffing Failure to educate Punitive environment Lack of Leadership Electronic Health Records Increasing Complexity of Medicine

Ignorance Inexperience Faulty Judgment Fatigue & Job Overload Failure to Monitor System Flaws COMMON CAUSES of MEDICAL ERRORS Lack of Leadership Electronic Health Records Heavy reliance on its accuracy Note bloat Multiple programs Increasing Complexity of Medicine

COMMON CAUSES of MEDICAL ERRORS Ignorance Inexperience Faulty Judgment Fatigue & Job Overload Failure to Monitor System Flaws Lack of Leadership Electronic Health Records Increasing Complexity of Medicine Living longer More co-morbidities

Barriers Encountered at ECU Attitude Blame The Coolness Factor Technology Time pressures Individuals Leadership Trainees Cultures Formal curriculum

Top seven barriers to implementing patient safety systems: Competing priorities for scarce resources in a system where patient safety is not considered a top priority Lack of resources: inadequate staffing and work overloads Availability and cost of patient safety technology Resistance to change (the assumption that providers are already providing safe care) Culture of blame (current healthcare culture is punitive in nature) Lack of senior leadership understanding of and involvement with patient safety issues Culture of healthcare workforce perceptions, attitudes and behaviors of error cover up Akins RB, Cole BR. Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications. J Patient Saf 2005; 1:9-16.

Starts with YOU! Create a culture of emphasizing patient safety Recognizing pervasiveness throughout patient care encounters Training individuals Faculty Chief Resident of Patient Safety Residents and mock root cause analyses (RCAs) Design a formal curriculum Using a variety of educational methods Didactics Role model on service Small groups and role play Collaborative process HOW DO WE FIX THESE ISSUES?

CURRICULUM GOALS Assumption that errors will occur Emphasis on systems rather than individuals Emphasis on the multifactorial nature of error Emphasis on caregiver interactions Emphasis on a non-punitive environment Balance between positives & negatives Leadership from the top down

Lectures Why do we teach patient safety Definitions Event Reporting Heuristics IHI Open School Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Validation of skills Transparency Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis CURRICULUM

CURRICULUM Lectures Morbidity & Mortality Conferences Debriefing of an adverse outcome or patient death Routine Patient Safety Conferences Error Reporting Validation of skills Transparency Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis

CURRICULUM Lectures Morbidity & Mortality Conferences Routine Patient Safety Conferences Education on new order sets, policies, protocols, etc. Updates on recent changes within the system Error Reporting Validation of skills Transparency Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis

CURRICULUM Lectures Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Importance of safety event and near miss reporting How are reported safety events handled How do we report events and what events are reportable Updates on reported events Validation of skills Transparency Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis

CURRICULUM Lectures Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Validation of skills PGY-2 ACLS & BLS recertification w/ practice scenarios Mock Code Blue PGY-2 Central Line Placement Assessment Transparency Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis

CURRICULUM Lectures Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Validation of skills Transparency Internal Medicine Unit HCAPS scores Patient Satisfaction scores Hospital HCAPS scores Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis

Lectures CURRICULUM Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Validation of skills Transparency Leadership Top-down Attending on rounds Chief residents Senior residents Program and Associate Program Directors Quality and safety chief resident Faculty mentor Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis

CURRICULUM Lectures Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Validation of skills Transparency Leadership Multidisciplinary approach Team based learning Simulation Inviting other disciplines to M&M, RCA, etc. Engaging Educational Activities (Make it fun) Root Cause Analysis

CURRICULUM Lectures Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Validation of skills Transparency Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Patient Safety Jeopardy/Bingo Daily Bonus Questions Residency class event reporting competition Root Cause Analysis

CURRICULUM Lectures Morbidity & Mortality Conferences Routine Patient Safety Conferences Error Reporting Validation of skills Transparency Leadership Multidisciplinary approach Engaging Educational Activities (Make it fun) Root Cause Analysis Systems approach to a serious safety event Non-punitive approach to events

ROOT CAUSE ANALYSIS Insanity is doing the same thing and expecting a different result -Albert Einstein

RCA: Definitions *RCA is a tool designed to help identify not only what and how an event occurred, but also why it happened 1. Root causes are specific underlying causes 2. Root causes are those that can reasonably be identified 3. Root causes are those management has control to fix 4. Root causes are those for which effective recommendations for preventing recurrences can be generated

RCA: ESSENTIAL STEPS 1. Data Collection 2. Causal Factor Charting Individual System 3. Root Cause Identification 4. Recommendation Generation & Implementation

RCA: SIMPLE EXAMPLE Available at: http://www.chemicalprocessing.com/cartoon-caption/cartoon-caption-1/cartoon-caption-71/. Accessed April 27, 2015

Scenario RCA: DATA COLLECTION 45 y/o patient with stage IV colon cancer admitted to surgical oncology on 6/30/14 with abdominal/back pain, jaundice, and increased liver functions test levels indicating possible obstruction. Patient has had complicated course over the past year with multiple procedures and brain metastasis with subsequent seizure activity (5/2014). As a result, patient started on levetiracetam. On admission, levetiracetam was not started on day of admission. On 7/6/14, patient experienced seizure activity and required transfer to ICU. Levetiracetam then restarted. Patient continued to have complicated course and ultimately decided to pursue DNR/DNI with eventual demise.

Establish Cultural Change- Convert the gadget to a Mindset Expect the Expected (i.e. Mistakes) Program Variability System solutions, not individual Implement a Mock-RCA s at your program level

Components of a Curriculum Swiss Cheese Model Just-Cultural Algorithm Sample RCA Roles of RCA Members List of Useful Resources Patient Safety Intelligence Handbook

1. Akins RB, Cole BR. Barriers to implementation of patient safety systems in healthcare institutions: leadership and policy implications. J Patient Saf 2005; 1:9-16. 2. Coombes ID, Stowasser DA, Coombes JA, Mitchell C. Why do interns make prescribing errors? A qualitative study. Medical Journal of Australia 2008; 188(2):89-94. (adapted from Reason's model of accident causation.) 3. George C. Biddle: Civil War Soldier. https://snyderfamilyhistory.wordpress.com/2013/05/27/george-c-biddle-civil-war-soldier/. Snyder-Lucas Family History, April 2015. 4. http://www.chemicalprocessing.com/cartoon-caption/cartoon-caption-1/cartoon-caption-71/. Chemical Processing, April 2015. 5. http://www.ihi.org/education/ihiopenschool/pages/default.aspx. Institute for Healthcare Improvement, March 2015. 6. http://www.iom.edu/. Institute of Medicine of the National Academies, April 2015. 7. http://uicpatientsafetycurriculum.org/documents/links%20for%20patient%20safety%20educators/patient%20safety%20curric ulums/psep_participant_handbook.pdf. The patient safety education project: participant s handbook, April 2015. 8. 2014 Quality & Safety Educators Academy. http://sites.hospitalmedicine.org/qsea/. 9. Rooney JJ, Heuvel LNV. Quality basics: root cause analysis for beginners. Quality Progress 2004; 45-53. 10. Telluride Patient Safety Summer Camps. http://telluridesummercamp.com/. 11. VA National Center for Patient Safety. http://www.patientsafety.va.gov/professionals. U.S. Department of Veterans Affairs, March 2015. 12. WHO patient safety curriculum guide. http://www.who.int/patientsafety/education/curriculum/en/. World Health Organization, March 2015. 13. Wu AW, Lipshutz AKM, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA 2008; 685-7.

Institute for Healthcare Improvement Open School WHO Patient Safety Curriculum Guide The Patient Safety Education Project Institute of Medicine VA National Center for Patient Safety Seminars Telluride Patient Safety Summer Camps Quality & Safety Educators Academy

The world changes according to the way people see it, and if you can alter, even by a millimeter, the way people look at reality, then you can change the world. - James Baldwin

Feel free to email us with any remaining questions Please fill out the evaluation forms for proper feedback GOOD LUCK NEXT YEAR! Email: Suchita Pancholi, MD- pancholis@ecu.edu Email: Letitia Cameron, MD- camerony@ecu.edu Email: Aniel Rao, MD- raoa@ecu.edu Email: Michael Hill, MD- hillmi@ecu.edu