Improved Patient Care and Safety David Fitzgerald, CCP, LP Division of Cardiovascular Perfusion College of Health Professions Medical University of South Carolina ARS Question #1 In my department/unit, we are actively doing things to improve patient safety Strongly agree Agree Neither Disagree Strongly disagree ARS Question #2 When an event is reported, it feels like the person is being written up, not the problem Strongly agree Agree Neither Disagree Strongly disagree 1
ARS Question #3 My supervisor/manager overlooks patient safety problems that happen over and over Strongly agree Agree Neither Disagree Strongly disagree ARS Question #4 Staff will freely speak up if they see something that may negatively affect patient care Always Most of the time Sometimes Rarely Never ARS Question #5 When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? Always Most of the time Sometimes Rarely Never 2
Patient Safety Application of safety science methods toward the goal of achieving a trustworthy system of health care delivery 1 An attribute of health care systems that minimizes the incidence and impact of adverse events and maximizes recovery from such events 1 Patient safety is freedom from healthcare associated, preventable harm 2 1- Emanuel L et al. http://www.ahrq.gov 2- http://www.evidenceintopractice.scot.nhs.uk/patient-safety/what-is-patient-safety.aspx Patient Safety World Health Organization s World Alliance for Patient Safety Surgical Unit-based Safety Program (SUSP) Surgical Site Infection control in Kenya and Uganda WHO Safe Childbirth Checklist 130 million births 303,000 mothers, 5.3 million children die WHO Guidelines Safe Surgery Surgical Safety Checklist Pulse Oximetry Project Patient Safety in Robotic Surgery: SAFROS Project Global initiative for Emergency and Essential Surgical Care WHO: 10 Facts on Patient Safety 1. Patient safety is a serious global public health issue 2. One in 10 patients may be harmed while in the hospital (developing nations) 3. Hospital infections affect 14 out of every 100 patients admitted 4. Most people lack access to appropriate medical devices 5. Unsafe injections decreased by 88% from 2000 to 2010 6. Delivery of safe surgery requires a teamwork approach 7. About 20-40% of all health spending is wasted due to poorquality care 8. A poor safety record for health care 9. Patient and community engagement and empowerment are key 10. Hospital partnerships can play a critical role 3
Purpose: Chart 5-1. Composite-Level Average Percent Positive Response 2014 Database Hospitals Comparison Assessment and Learning Supplemental Information Trending 42 Items that measure 12 composites of pt. safety Communication openness Feedback and communication about error Frequency of events reported Handoffs and transitions Management support for patient safety Non-punitive response to error Organizational learning- continuous improvement Overall perceptions of safety Staffing Supervisor expectations and actions promoting safety Teamwork across/within units Assessing the Culture of Safety in Cardiovascular Perfusion: Attitudes and Perceptions Chad Lawson, Megan Predella, Allison Rowden, Jamie Goldstein, Joseph J. Sistino, David C. Fitzgerald Division of Cardiovascular Perfusion College of Health Professions Medical University of South Carolina Survey broadcasted through email invitation (Perflist, Perfmail and LinkedIn) 37 closed, Likert-scaled questions based on AHRQ Hospital Survey on Patient Safety Culture >75% agree or strongly agree Overall work unit grade of patient safety Culture of Safety Highest Scoring Categories 4
Culture of Safety Lowest Scoring Categories Joint Commission- 5 Principles of a Learning Organization Team learning Shared visions and goals A shared mental model Individual commitment to lifelong learning Systems thinking Must have a fair and just safety culture, a strong reporting system, and a commitment to put data to work by driving improvement. http://www.jointcommission.org/assets/1/6/psc_for_web.pdf How to Promote Patient Safety Limiting Blame Fallacy: Well-trained and conscientious practitioners do not make mistakes Systems Thinking Standardization and simplification Transparency and Learning Sharing information about medical errors 1- Emanuel L et al. Available at: http://www.ahrq.gov 5
Patient name/procedure Age/Allergies Stage of the procedure Status of temperature History Circuit Lab values and targets Anticoagulation Medications Pump settings Other conditions or concerns Fluid status Final thoughts surgical approach, cannulation, backup plan, target flows medications, adverse reactions, associated risks preoperative, perioperative, postoperative, surgical status target temperatures, current temperatures, rewarming rate symptoms, risk factors, diagnosis, prior procedures, preoperative medications oxygenator, tubing size and coating, cardioplegia, shunts, hemoconcentrator, accessories hematocrit, blood gasses, electrolytes, enzymes, targets status, targets, heparin use, alternative anticoagulants, blood components vasoconstrictors, vasodilators, cardioplegia, electrolytes, antiarrhythmics, colloids FiO2, sweep, blood flow, vacuum, RPMs, timers, shunts jehovah s witness, sickle cell anemia, pregnancy, sepsis, DIC I/Os, crystalloid use, ultrafiltrate amount and rate, urine 3/17/2016 How to Promote Patient Safety Culture and Professionalism Collective mindfulness - High-Reliability Organizations Search for and report unsafe conditions before they pose a substantial risk and when they re easy to fix Accountability for Delivering Effective, Safe Care Joint Commission- 20,000 centers accredit/certify Commitment to continuous learning / Published literature Health Care as an Industry Partnerships Human factors engineering in health care How to Promote Patient Safety Rethinking Risk Quality improvement Risk management Emphasizing Teamwork Relationships between coworkers which can lead to failure, including both individual errors and inherent weaknesses within a system. Reason s model likens this to slices of Swiss cheese, with the holes in the cheese representing potential weaknesses. If a hazard arises, it can progress through a hole in the first slice; that is, a weakness in the first stage of the process will allow it to go unchecked. But ideally, the hazard will encounter a solid section of cheese in a subsequent slice, and progress no further; i.e. one of the subsequent stages of the process will identify the hazard and prevent it developing. Figure 1: Patient Safety Swiss Cheese Model 30 However, if a system is set up in such a way that holes in the cheese can become aligned across all slices, then a hazard could develop unchecked, and eventual failure of the system is inevitable. I PASS THE Therefore, CLAMP OFF in Reason s model, maximising safety requires more slices, and smaller and fewer holes; i.e. more defence stages across a model, and fewer and better-identified weaknesses Patient Handoff Tool at for Perfusionists each stage, minimising the aligned-weakness outcome. 31 I Isolation precautions contact, droplet, airborne The Three Bucket model P A Reason s three bucket model 32 S aims to help clinicians take an appropriate approach to S considering their surrounding and limitations, so as T to estimate Transfusion the degree blood type, of targets, risk product use, present, availability and from a number of perspectives. H E Equipment condition mechanical concerns or issues The model C advises staff to consider three areas in which L risks may be present Self, Context A and Task and in the model, illustrates these M as three P separate buckets. At any one time, each O bucket will be filled with a mixture of Good Stuff F and Bad Stuff ; and the overall risk of error F in a task will be in line with the total amount of Bad Stuff present across all three buckets. Figure 2: Reasons Three Bucket Model 33 The NPSA have produced examples of factors which may be present in the three buckets 34 e.g. in the Self bucket, knowledge, skill, expertise, as well as their current capacity. If workload, fatigue and stress levels all increase, the Self bucket will contain more Bad Stuff, and the risk of error rises. All buckets are then considered. An example of this is given by McKimm & Forrest 35 : if a clinician were to insert a cannula to a compliant patient with large veins at the start of a day shift, they would not likely foresee any issues. But if the patient were uncooperative, and an intravenous drug user with poor veins; it were the middle of the night; and the clinician were tired, stressed and hungry, then ideally the clinician should stop and consider their three buckets as being full, and so reconsider the task before deciding how best to proceed. Royal College of General Practitioners- Implications of General Practice Workload Joint Commission Standard LD.04.04.05 The hospital has an organization-wide, integrated patient safety program This standard describes a safety program that integrates safety priorities into all processes, functions, and services within the hospital, including patient care, support, and contract services. It addresses the responsibility of leaders to establish a hospital-wide safety program; to proactively explore potential system failures; to analyze and take action on problems that have occurred; and to encourage the reporting of adverse events and near misses, both internally and externally. The hospital s culture of safety and quality supports the safety program. At least every 18 months, the hospital selects one high risk process and conducts a proactive risk assessment. At least once a year, the hospital provides governance with written reports on all actions taken to improve safety, both proactively and in response to actual occurrences 6
Identifying Risks Incident reports Near-misses Environmental tours Issues reported by Patient Safety Officer Observations by staff members Publications New regulatory issues Joint Commission Sentinel Events Product Recalls Audits, inspections Industry Standards and Guidelines Simulation exercises Time-outs, briefings, debriefings Failure Mode & Effect Analysis (FMEA) Summary 7