1 / 52

Patient Safety And Communications Building Stronger Teams

Patient Safety And Communications Building Stronger Teams. Nazir Habib MD, ICU Kaiser Vallejo. Objectives. BACKGROUND: patient safety/medical errors Reasons for medical errors Role of Teams in preventing errors Building stronger teams Understand role of “Human Factors”

lesley-good
Download Presentation

Patient Safety And Communications Building Stronger Teams

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Patient Safety And CommunicationsBuilding Stronger Teams Nazir Habib MD, ICU Kaiser Vallejo

  2. Objectives • BACKGROUND: patient safety/medical errors • Reasons for medical errors • Role of Teams in preventing errors • Building stronger teams • Understand role of “Human Factors” • Learn effective communication tools • Implement change in systems • Reduce erors

  3. Medical errors • 1999 report from IOM “to Err is Human” • Up to 98,000 patients die in hospitals from errors ( 300 patients/day) • 5 million patients injured • Cost up to $38 billion • Consumers(leapfrog), • Media and lawyers • JCAHO priority

  4. Media attention

  5. Extent Of Medical Errors Weingart. BMJ VOLUME 320 18 MARCH 2000 • 5th leading cause of death in USA • Exceeds deaths from MVAs, breast cancer or AIDS • 2-5% Hospital admissions • Annually deaths exceeds deaths in Vietnam and Korea combined

  6. Comparison: annual deaths

  7. Definitions: • Adverse event is an injury caused by medical management and not the illness. Most due to error or hazardous environment. • Error is an unintended act that does not achieve the intended outcome. • Near miss is event that could have caused an adverse event. • Sentinel event is an unexpected event leading to death or serious injury.

  8. Patient Injuries: 5 million lives (IHI.org) • Medication errors • Missed treatment and Dx/delays • Falls and injuries, HAPU • Delirium and confusion • Infections: Nosocomial or hospital acquired: • IV and central lines • Pneumonia (HAP) or VAP • Surgical sites/wound • C. Diff infections at epidemic level • UTI from foley • Pressure ulcers

  9. Nosocomial Infections • 5-6% hospital admissions • Surgical, bloodstream, pneumonia and UTIs: 2 million/year • Causes 100,000 deaths • 30% are preventable • Increase length of stay and cost • Resistence: VRE,MRSA,DRSP, pseudomonas

  10. Medication Errors

  11. Accident Causation Latent Failures Attention Distractions Incomplete Procedures Deferred Maintenance Inadequate Training Clumsy Technology Triggers Psychological Precursors Unsafe Acts Organization Team Accident Individual Defenses Technical Modified from Reason, 1990

  12. Human Factors and Patient Safetywww.patientsafetyfirst.nhs.uk • Human factors encompass factors that can influence people environment and their behaviour. • Complex interaction of psychological and social factors and work environment that will impact outcomes, attitudes, morale and team work • Individual characteristics/organization structure, leadership culture and system process which influence behaviour at work.

  13. Causes of Errors

  14. Errors Occur……..Because • Excessive professional courtesy. Hierarchy .. team members fail to point out deficiencies in performance or systems.Halo effect— clouds our judgment. • Passenger syndrome—Team members experience “passenger syndrome” (“just along for the ride”) when they abdicate responsibility …someone else is in charge. • Hidden agenda..Personal gains not team or patient • Complacency: individuals and teams lose their vigilance and situation awareness. • High-risk phase—a procedure or time in which a medical mishap is likely to happen (e.g., shift change). • Task (target) fixation. Performance and time issues

  15. Define Communication…. • Communication is the exchange of information between 2 people, groups, or entities. • The word communicationencompasses many types of exchanges, such as verbal and written…. • Consider body language, facial expressions, tone, eye contact….80% • The biggest problem with communication is the illusion it is taking place ……GB Shaw quote

  16. Communications/ Human Factors • Poor Training/skills/competence • Fatigue/Overwork/Staffing level • Processes eg.Hand-0ffs • Distractions • Punitive culture/fear • Hierarchy • Intimidation • “Who is a right” vs “Doing the right thing” • Personal agenda vs TEAM..

  17. Have Overworked Staff..?

  18. Critical Events: Case Presentation • 65 yr male is 3 days post-op colectomy on a PCA morphine pump. • PMH: Obesity BMI is 40, DM • 8 pm exam: Temp 101 F, RR 28, O2 sats 93%, HR 120, BP 94/58 • Which vital sign is most important predictor of critical illness? • ?Could this patient die before 8 am??? • What is your assessment? • What will you communicate to the MD?

  19. Can We Predict Clinical deterioration? Slippery slope.. How do you know? SAFE Zone “RED Zone” “Dead Zone”

  20. INDEPENDENT PREDICTORS OF MORTALITY AT HOSPITAL DISCHARGE (Buist et al, Resus 2004) • OBSERVATION/EVENT • RR < 6/min • RR > 30/min • LOC change • SaO2 < 90% • BP < 90 mmHg • ODDS RATIO ( 95% CI) • 12.3 (2.2-69.6 • 6.5 (3.6-11.8) • 6.6 (3.1-13.9) • 2.6 (1.7-3.9) • 2.5 (4.6-7.4) njh

  21. Who is watching the patient..?

  22. Vital Signs Deteriorating…? Vitals are vital!!!

  23. JCAHO : Safety Goal Rescue patients • 5-10% patients on the floor deteriorate after admission • Which physiological parameters predict a deterioration in patient or impending code blue? • Often in the first 24 hours • Often failure to recognize severity of illness • Failure to stabilize the patient • Poor or Failure to communicate is the most COMMON reason for error • >50% patients care is suboptimal • MAJORITY code blues are preventable

  24. Do We Have A Plan..?

  25. MEDICAL EMERGENCY TEAM..?

  26. MET CRITERIA

  27. Results • Reduction in Adverse outcomes: • Respiratory failure 79% (75 vs 15) • Stroke 78% (19 vs.4) • Severe Sepsis 75% (18 vs 4) • Renal failure 88% (27 vs 2) • ICU admissions reduced 44%: only 8 pts. Transferred to ICU

  28. Primary Survey:Brief! • Examination • First --Brain: LOC ? Neuro? • Airway/Breathing RR and WOB , O2 sats! • Circulation: BP, extremities

  29. Secondary Survey • Examination • Respiratory • Cardiovascular • Abdomen and genitourinary tract • Central nervous system • Peripheries • Data: Medications, procedures,PMH,allergies etc • Trends : vitals and labs…. • GET ALL the information before you call…..!!!!!

  30. How Do Your Doctors and Nurses Communicate..? • Differences in the style of communication? • Inadequate training and coaching • Role of Simulations ? • Organization Culture ? Level of empowerment of frontline staff? Leadership? • Level of mutual respect? • Poor past experiences? Feedback constructive and trended..? • Expectations not set-feedback regular? • Perceptions of teamwork?

  31. Behavior : Intimidation Problem • The Joint Commission also introduced a new standard in 2009 (LD.03.01.01) requiring accredited organizations to create a code of conduct that defines acceptable and unacceptable behaviors and to establish a formal process for managing unacceptable behavior. • Develop a system to detect and receive reports of unprofessional, disruptive, and intimidating behavior • J Nurs Care Qual. 2009. 24, No. 3, pp. 184–188 D.Nadzam

  32. Physician Nurse Communications • IDENTIFY physician by name. PATIENT by name!! NOT ROOM NUMBER please, USE I.SBAR • Have patient information and the chart readily available. • Clearly express any concern about the patient and the reason for that concern. • Recommendation. Questions • Focus on the patient problem, not extenuating circumstances. • Be professional, not aggressive. • Read back , ask questions to clarify , use judgement

  33. Communicate Crisis Clearly….. • Situation: I am calling about patient…why? • Background: Why is the patient in hospital? PMHX? Meds? • Assess: Severity of acute physiology • Look at data, gather all information. • ASSESS pt. Look at the trends..what do you think? • Recommend: intervention, test….?

  34. SBAR ?Focused

  35. SBAR focus

  36. * Assertion

  37. Novice to Expert Technical Skills Novice Advanced Beginner Competent Proficient Expert Teamwork & Communication Skills

  38. JCAHO: Failure /Barriers • Lack of awareness/priority • Culture of blame and punitive action • Hierarchy • Failure of communication • Leadership not involved- Departments work in silos • Poor structure for quality improvements • Outmoded information systems • Poor understanding of system or issues • No data

  39. Medical Culture- The Upside • Best and Brightest • Brutal Training- Elite Cadre • High Personal Standards • Amazing Work Ethic • Great attitude-want to do a good job

  40. Predicts nurse stay… • Job Satisfaction- I like what I do, OR • Teamwork- I like to be on with MD/RN?RT?…. • Top 3 predictors of nursing turnover: • Doctors and nurses work together as a team • I can speak up if I disagree with physicians • Disagreements in this unit are resolved with what is right for the patient • Open learning environment-ok to challenge concepts • “We have always done it this way” • Learn together….

  41. “The Take Home Messages” • Learning environment • Communication is very important • Get ALL information together • Know your patients..read • Make rounds with the doctor • ASK questions, engaged and interested • LEARN something new daily/ reading • Build better teams • Have Fun……with medicine!

  42. We can work as ….Teams

  43. Teams: Think Feel DO !! • Knowledge /Skills/Training • Key factor and is the foundation of strong teams • Attitudes • Team focus, collaboration • Behaviour • Communication • Performance • Task • Safe practice • Application

  44. Identifying Opportunities to Use Team Building Tools and Strategies

  45. Exercise: Role playing SBAR Technique Break into groups of 6 = Case presentations Diabetic with pneumonia BS is 40 70 yr female Fx hip is confused on day 2 60 yr post op colectomy Hg is 9.2 at 6 pm Patient on heparin drip for PE has BP 85/50 and HR 120 /min Evaluate case/Present case use SBAR =call MD Sign out patient to next shift or Break End of shift GOALS of care

More Related