CUSP/Stop BSI Collaborative of Kansas and Missouri

1. Document 2, June Coaching Call CUSP/Stop BSI Collaborative of Kansas and Missouri June Coaching Call: Learning from a Defect June 2, 2011 Kimberly O’Brien, MHA Tonya Crawford Project Manager Program Manager Missouri Center for Patient Safety Kansas Healthcare Collaborative Jefferson City, MO Topeka, KS kobrien@mocps.orgtcrawford@khconline.org

2. The “Secret Ingredient”Comprehensive Unit-Based Patient Safety Program • Form a unit CUSP team with executive sponsorship • Measure unit culture • Educate staff on Science of Safety • Identify defects using the Staff Safety Assessment; prioritize defects • Learn from one defect per quarter • Implement team/communication tools

3. Step 4: Prioritize Defects

4. Prioritize Defects • Collate and categorize the ‘How the next patient will get harmed’ responses • Multivoting • Purpose: To narrow a long list of possibilities to just on that your team can work on

5. Prioritize DefectsMultivoting • Instructions: • Create the list and number the items • Give each team member a number of ‘votes’ equal to about 1/3 of the total number of items • Have team member ‘vote’ for items (can create criteria for selection-greatest risk for pt or most frequent occurrence) • List the number of votes each item gets • Briefly discuss and eliminate items with fewest votes (want list of 3 or less) • Pick the one with potential largest impact or highest risk to work on

6. Step 5: Learn from a Defect

7. Learn from a Defect • Designed to rigorously analyze the various components and conditions that contributed to an adverse event and is likely to be successful in the elimination of future occurrences. • Tool can serve to organize factors that may have contributed to the defect and provides a logical approach to breaking down faulty system issues 7

8. Learn from a Defect • Select a specific defect • What happened? • Why did it happen (system lenses) ? • What could you do to reduce risk ? • How do you know risk was reduced ? • Creates early wins for the project 8

9. Learn from a Defect Tool Appendix G from the CUSP Implementation Toolkit Divided into three sections: Section 1 asks the users to identify what happened or the defect they want to investigate Section 2 is a framework provided for the investigators to identify any contributing factors. These factors include: patient, task, caregiver, and team related, training and education, local environment, information technology and institutional environment. Section 3 asks participants to develop an action plan with assigned responsibility for task completion and follow up dates for each item. 9

10. Case Scenario: A patient is scheduled for an elective procedure. Pt completes a Pre-Op visit with the Pre-Op RN. On the scheduled day of surgery, the Ambulatory Care RN (AC) reviews Pre-OP RN’s documentation and notes any changes. The AC RN reviews physician's orders and depending on the antibiotic administration practices, the AC RN may start the administration of an antibiotic. Med administration might be documented in electronic “Surgery Module” or handwritten on a Patient Appointment Record (NOT a part of the permanent record) until it can be documented in the patient’s medical record. When the OR Team is ready for the patient, the patient is transported to OR suite and introduced to the OR Team (OR circulator & CRNA). The OR team might get verbal notification that antibiotics have/have not been given or need to be started. This can lead to an extra dose being given or a dose being omitted. The team identified Toradol as another medication that has the potential of being administered too soon from the last administered time. If the medication is administered in the OR, the CRNA documents on the paper Anesthesia Record. The Anesthesia record is copied and sent to the Pharmacy along with the used Anesthesia kit for refilling. It is the next day when Pharmacy sees the “last time administered” recorded and therefore cannot profile the medication in the Pharmacy Module prior to administration of the med. The CRNA performs handoff to the PACU RN for recovery. The CRNA may still be completing Anesthesia record. Therefore, the PACU RN does not have the documentation available for the last dose of antibiotic. PACU RN performs handoff to unit RN and does not have the info of the last dose given of either the antibiotic or the Toradol. The Unit RN relies on Pharmacy to profile the antibiotic for the appropriate time frame on the eMAR based on the info Surgery gave the Pharmacist. Oops, the patient gets a double dose. System Failures Opportunities for Improvement: Team Factor: Verbal/written communication Inconsistent with handoff Standardize handoff communication throughout the Preoperative episode of care. Assure critical information is shared timely and consistently by incorporating both verbal and written handoff during transfer of care Information Tech/CPOE Factor: Computer documentation fragmented due to multiple modules. Not everybody using computerized documentation Long-term organizational goal is to have a completely electronic, standardized, integrated, real-time medical record to eliminate duplicate documentation Institutional Environment: 24 hour pharmacist not available. In Surgery dept, physician present has overall accountability of medication dispensing / administering. Relies on human for double checks. Discussion occurring at Administration level on the feasibility to have a 24 hour Pharmacist on duty. This would not necessarily improve the outcome of this particular situation within the OR • ACTIONS TAKEN TO PREVENT HARM • PeriOperative Safety Team will adapt the “Patient Appointment Worksheet” using the TeamSTEPPS Handoff Communication Tool, “I PASS the BATON” • The handoff tool will be standardized for the PeriOperative area so that the critical information is consistent and comparable regardless of the nurse doing the handoff • The handoff will include the date/time of last antibiotic administered • The Team will implement this tool with the Women’s Center (WC) RN’s since the WC RN’s take the role of Circulating RN and Recovery RN when the patient presents for a C-section (scheduled or unscheduled)

11. What will you do to reduce risk ? • Prioritize most important contributing factors and most beneficial interventions • Safe design principles • Standardize what we do • Eliminate defect • Create independent check • Make it visible • Safe design applies to technical and team work 11

12. What will you do to reduce risk? • Develop list of interventions • For each Intervention rate • How well the intervention solves or reduces the problem • The team belief that the intervention will be used as intended • Select top interventions (2 to 5) and develop intervention plan • Assign person, task follow up date 12

13. Rank Order of Error Reduction Strategies Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Be more careful, be vigilant

14. How do you know risks were reduced? Did you create a policy or procedure (weak)? Do staff know about policy or procedure? Are staff using the procedure as intended? Behavior observations, audits Do staff believe risks were reduced?

15. Summarize and Share Findings • Summarize findings using the Case Summary Form (Appendix F of the CUSP Implementation Toolkit) • Share within your organizations • Share de-identified with others in collaborative (pending institutional approval)

16. What are your next steps? Collate and categorize the staff safety assessment results Select a defect to solve this quarter If you’re ready, apply Learn from a Defect tool Learning from a Defect example will be discussed again during the July coaching call 16

17. Questions?