Sandra Trotter, MBA, MPHA, CPHQ PATIENT SAFETY PROGRAM LUCILE PACKARD CHILDREN S HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER
LUCILE PACKARD CHILDRENS HOSPITAL STANFORD UNIVERSITY MEDICAL CENTER PALO ALTO, CALIFORNIA Inpatient & Short Stay Total staffed beds = 272 Discharges = 14,001 Bed Days = 80,600 Occupancy % = 83.6% Clinics: Outpatient & Urgent care visits = 134,326
Mortality Rate Decrease (1/2005 to 12/2008)
Risk Adjusted (Observed/ Expected Ratio)
SAFE EVIDENCE BASED FAMILY & PATIENT CENTERED & ACCOUNTABLE PATIENT CARE TRANSPARENT Lucile Packard Children s Hospital PATENT SAFETY AND QUALITY OUTCOMES
The prevention of harm to patients One in five Americans (22%) reported that they or a family member has experienced medical error of some kind. Nationally this translates to an estimated 22.8 MILLION people with at least one family member who has experienced a mistake in a doctors office or hospital.
How do we ensure that we are providing safe care? - I m too busy - We don t have an aide today - The glove box was empty - No report when transferring patient - Didn t check ID bracelet
Sensory Overload Distractions in the environment Cognitive Rely on memory Overestimate abilities, underestimate limits Long shifts Sleep depravation Tendency for behavior to migrate out of compliance Hand Hygiene BASICALLY- BECAUSE WE ARE HUMAN
Our systems are too complex to expect merely extraordinary people to perform perfectly 100% of the time. We as leaders have a responsibility to put in place systems to support safe practice. James Conway former VP and COO Dana-Farber Cancer Institute
Reliability means doing the right thing, in the right way, at the right time every time. Healthcare processes have poor reliability Complex Multi-step Not standardized Many handoffs Poor communication
There are tools available free of charge to measure the safety attitudes in your hospital. http://www.ahrq.gov/qual/hospculture 42 41 40 39 38 37 36 35 Results by Safety Climate Provision of Safe Care LPCH All Children's Hospitals All PSC Hospitals Lower is Better In the last year, I have witnessed a coworker do something that to me appeared unsafe for the patient.
An important Culture of Safety principle is to reduce the fear of blame. Anonymous incident reporting allows staff to report incidents without fear of punishment. These incident reports can be used to learn, improve and prevent further errors.
One of the key recommendations from the Institute of Medicine report in 1999, entitled To Err Is Human hospitals must study near misses to detect system weakness before the occurrence of serious harm. Incidents that have caused serious harm are consistently reported but these reports are after the fact. In order to achieve the highest possible level of safety, incidents in which harm was averted must also be consistently reported!
It is the responsibility of the leaders, staff and physicians to take action to address the incidents and make sure they don t happen again. It s a bigger tragedy to learn about a potential error and fail to take action.
This was an accident waiting to happen. The 10,000 dose vial looks almost the same as the very low dose vial used to flush the IV lines. All of us have to look at the environment and design for safe care.
We were told by upper Cedars-Sinai administration that our children had received only one 10,000 unit dose of heparin when in fact they had received two 10,000 unit doses over an eighthour period that we now know of. The hospital s lack of candor has left us with the uneasy feeling that we may never know the whole story,
System Barriers to Safe Health Care Amalberti et al. (2005). Annals of Internal Medicine Allowing professional hierarchies to prevent structured communication of critical information Solution: Structured Communication SBAR for routine communication CUSS to communicate concern C I m Concerned or I need clarity U Uncomfortable S Stop the line/procedure S Patient Safety is at risk!
Between workers and across organizational levels PATIENT SAFETY CHAMPION MEETINGS ONCE A MONTH
Human beings, by their nature, learn from the experience of others. We must be willing to share our mistakes as well as our successes. Once a month, an actual reported incident that occurred at LPCH is shared with front line staff. Staff is asked for suggestions to prevent the incident from reoccurring.
SAFE EVIDENCE BASED FAMILY & ACCOUNTABLE & PATIENT CENTERED PATIENT CARE TRANSPARENT Lucile Packard Children s Hospital PATENT SAFETY AND QUALITY OUTCOMES
Patient Safety is Every Patient s Right and Everyone s Responsibility
Sometimes... BECAUSE SOME PEOPLE TAKE RISKS
CMS No-Pay List October 2008 1. Object inadvertently left in after surgery 2. Air embolism 3. Blood incompatibility 4. Catheter associated urinary tract infection 5. Pressure ulcer (decubitus ulcer) 6. Vascular catheter associated infection 7. Surgical site infection- Mediastinitis (infection in the chest) after coronary artery bypass graft surgery 8. Certain types of falls and trauma
NP4NP Failure to report will result in a 2% point reduction in the Annual Payment Update (APU) for inpatient hospital services Is it really Pay for Performance (P4P) or Is it No Pay FOR No Performance?
SAFE EVIDENCE BASED FAMILY & PATIENT CENTERED & ACCOUNTABLE PATIENT CARE TRANSPARENT Lucile Packard Children s Hospital PATENT SAFETY AND QUALITY OUTCOMES
Adverse events in health care are one of the leading causes of death and injury in the United States today. The National Quality Forum s list of 28 events provides the basis for the list that many states require to be reported. Minnesota has had a mandatory reporting program for never events in place for 4 years and has averaged roughly 100-150 reported never events per year.
REQUIRED PUBLIC REPORTING Already 19 states have passed laws that make hospital infection rates publicly available so consumers can make informed decisions as to where they will obtain their healthcare AND 27 states have mandatory adverse event reporting
SAFE EVIDENCE BASED FAMILY & PATIENT CENTERED & ACCOUNTABLE PATIENT CARE TRANSPARENT Lucile Packard Children s Hospital PATENT SAFETY AND QUALITY OUTCOMES
Encourage families to speak up if they have questions or concerns. Empower families to make sure the patient is getting the right treatments and medications Allow families to participate in all decisions about the treatment. The patient/family is the center of the health care team.
Provide Families with Education about the Diagnosis, the Medical Tests, and the Treatment Plan. Many Resources are Available Promoted by Joint Commission and other Healthcare Quality Organizations Partner with Patients and Families Encourage Patient Advocates
Our Family and Patient Website
SAFE EVIDENCE BASED FAMILY & PATIENT CENTERED & ACCOUNTABLE PATIENT CARE TRANSPARENT Lucile Packard Children s Hospital PATENT SAFETY AND QUALITY OUTCOMES
National Quality Forum Centers for Disease Control and Prevention National Coordination Council for Medication Error Reporting and Prevention Agency for Healthcare Research and Quality Joint Commission National Patient Safety Goals Institute for Safe Medication Practices Food and Drug Administration AND.
The Institute for Healthcare Improvement (IHI). Currently over 3,700 hospitals are enrolled (70-75% of all US hospital beds)
The six interventions from the 100,000 Lives Campaign: Deploy Rapid Response Teams Deliver Reliable, Evidence-Based Care for Acute Myocardial Infarction Prevent Adverse Drug Events (ADEs) Prevent Central Line Infections Prevent Surgical Site Infections Prevent Ventilator-Associated Pneumonia
New interventions targeted at harm: Prevent Pressure Ulcers Reduce Methicillin-Resistant Staphylococcus Aureus (MRSA) Infection Prevent Harm from High-Alert Medications Reduce Surgical Complications Deliver Reliable, Evidence-Based Care for Congestive Heart Failure Get Boards on Board
Technology CPOE Smart Pumps Wireless Monitor Interfaces Electronic Medical Record Trigger Tools Barcoding
PATIENT SAFETY COMES FIRST