The Science of Improving Patient Safety.pptx

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					The Science of Improving Patient Safety
Sean Berenholtz, MD, MHS, FCCM
September 4, 2012

Armstrong Institute for Patient Safety and Quality

Conference Number(s):800-779-9891
Participant Code:4757941
On Boarding Call Schedule

  •   Program Introduction
  •   Building Your CUSP Team
  •   Science of Safety –September 4, 2012 @2:00pm
  •   Building Your CUSP Team-September 11, 2012 @2:00pm
  •   VAP Evidence- September 18,2012 @ 2:00pm
  •   Daily Goal Review -September 25, 2012 @ 2:00pm

Learning Objectives

              Explain how every system is designed to achieve the results it gets
                        Identify and describe the basic principles of safe design
            Apply the principles of safe design to technical as well as teamwork
 Identify how teams make wise decisions when there is diverse and independent

Targeted Muscle Re-Innervation
(courtesy of Dr. Albert Chi)

1. Nerve Transfers

2. Motor Imagery (3 mo)

3. TMR Prosthetic (6 mo)

4. Sensory functions
The Problem is Large

• In U.S. Healthcare system
    – 7% of patients suffer a medication error           1

    – On average, every patient admitted to an ICU suffers an adverse event                       2,3

    – 44,000- 98,000 people die each year as the result of medical errors                     4

    – Nearly 100,000 deaths from healthcare-associated infections 5
    – Estimated 30,000 to 62,000 deaths from CLABSIs                6

    – Cost of HAIs is $28-33 billion 7

• 8 countries report similar findings to the U.S.

                               1.   Bates DW, Cullen DJ, Laird N, et al., JAMA,1995
                               2. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.
                               3. Andrews  L, Stocking C, Krizek T, et al., Lancet, 1997.
                               4. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.

                               5. Klevens M, Edwards J, Richards C, et al., PHR, 2007
                               6. Ending Health Care-Associated Infections, AHRQ, 2009.
How Can These Errors Happen?

• Every system is perfectly designed to
  achieve the results that it gets
   – majority of errors don’t belong to individual
     doctors or nurses
• People are fallible
• Need to view the delivery of healthcare as a
• Need systems that catch mistakes before
  they reach the patient
Rather than being the main instigators
 of an accident, operators tend to be
     the inheritors of system defects…..
    Their part is that of adding the final
garnish to a lethal brew that has been
                    long in the cooking.”

                     James Reason, Human Error, 1990

System Factors Impact Safety
Case Example

• 65 yo M s/p lung resection for cancer
• Admit to ICU; discharged to floor on post-op
  day (POD) 1
• POD 3 develops hypoxia
• Admitted to ICU, intubated
• CXR shows extensive left lung collapse
• Decision to perform broncoscopy

System Failure Leading to Error

                                    Did not verify
                                equipment availability


                                                         Bronch cart
                                                         not stocked

Patient suffers                Communication between
                                 resident and nurse
              Hypoxic arrest

Science of Safety

                                      Understand principles of safe design
   – Standardize, create checklists, learn when
     things go wrong

            Recognize these principles apply to technical and team work

  Teams make wise decisions when there is diverse and independent input

                            Health Services Research, 2006; Circulation. 2009;119:330-337   12
Eliminate Steps

Create Independent Checks

Healthcare-Associated Infections (HAI):
A Preventable Epidemic

                                               Focus on 4 HAIs:
   – VAP, CLABSI, surgical site infections and catheter
     associated urinary tract infections
                     $5 billion per year excess costs
                            1.7 million patients per year
   – 1 out of 20 patients
                                 98,000 deaths per year
   – As many deaths as breast cancer and HIV/AIDS
   – 6th leading cause of preventable deaths

 VAP Prevention Guidelines

• CDC Guidelines
     • MMWR Recomm Rep. 2004;53:1-36
• American Thoracic Society/Infectious Diseases
  Society of America
     • AJRCCM 2005;171(4):388-416.
• Canadian VAP Prevention Guidelines
     • J Crit Care 2008;23(1):138-147.
• Society for Healthcare Epid of
  America/Infectious Diseases Society of America
     • ICHE 2008;29:S31-S40.
Improving Care for Ventilated

 • Semirecumbant positioning

 • Peptic ulcer disease and DVT prophylaxis

 • Appropriate sedation

 • Daily assessment of readiness to extubate

 • Minimize contamination of equipment

Improving Care for Ventilated

                                     Educate staff
  Decrease complexity / create redundancy:
  – Daily goals checklist

              Other independent redundancies
  – Nursing and families
  – Are patients receiving the prevention they

Sample Daily

   •What needs to be
  done for the patient
   to be discharged?
  •What is the patients
   greatest safety risk?
  •What can we do to
     reduce the risk?
 •Can any tubes, lines,
         or drains be

 J Crit Care. 2003;18(2):71-75   19
Michigan Keystone ICU –

• 124 of 127 ICUs submitted VAP data
   – 12 ICUs started after funding ended
• 112 ICUs, 72 hospitals included in analysis
• 3228 ICU months and 550,800 vent days
• 10% quarters without complete data
   – 4% missing data; 6% stopped submitting data
• Sensitivity analysis yielded similar results
• Results reported through 28-30 months post-

Michigan Keystone ICU –
Bundle Adherence

Michigan Keystone ICU

                Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
Michigan Keystone ICU

Principles of Safe Design Apply to
Technical and Teamwork
breakdowns are
frequently the root
cause of…

Teams Make Wise Decisions When
There is Diverse and Independent Input

                                                            Wisdom of Crowds

     Redundancy is two sets of eyes trained differently looking at same picture

    Structured communication tools linked to improved patient and economic

Structured Communication

• Briefings and Debriefings
  – Reductions in complications;
    mortality 1,2

• Daily goals
  – 654 new ICU admissions; $7 million
    additional revenue 3
                          1   N Engl J Med 2009;360:491-9.
                          2   JAMA 2010;304(15):1693-1700.
                          3   J Crit Care 2002;18(2):71-5.

          Safety is a property
                    of systems
Action Items

Have all staff, unit leadership and executive leaders
 view the Science of Improving Patient Safety video

      Put together a roster of who needs to view the
     Science of Safety video, establish a timeline for
                      completion and track progress

  Finalize enrollment

• Complete and submit the
  commitment/enrollment form
• Questions or comments:

  – Karol G. Wicker, MHS
     Senior Director, Quality Policy & Advocacy
     Maryland Hospital Association

  – Mary Catanzaro RN BSMT CIC
     Project Manager HAIs
     Hospital and Healthsystem Association of Pennsylvania

Slide 6
1. Bates DW, Cullen DJ, Laird N, Peterson LA, Small SD, Servi D,
     Laffel G, Sweitzer BJ, Shea BF, Hallisey R, et al. Incidence of
     adverse drug events and potential adverse drug events. Implications
     for prevention. ADE Prevention Study Group. JAMA. 1995 Jul
2. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov
     R, Cotev S. A look into the nature and causes of human errors in the
     intensive care unit. Crit Care Med. 1995 Feb;23(2):294-300.
3. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T,
     Siegler M. An alternative strategy for studying adverse events in
     medical care. Lancet. 1997 Feb 1;349(9048):309-13.
4. Kohn LT, Corrigan JM, Donaldson MS. Committee on Quality of
     Health Care in America, Institute of Medicine. The National
     Academies Press. 2000.


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