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Quality Improvement

Quality Improvement. Principles of Safety for HIT. Lecture a.

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Quality Improvement

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  1. Quality Improvement Principles of Safety for HIT Lecture a This material (Comp 12 Unit 2) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

  2. Principles of Safety for HITLearning Objectives — Lecture a • Investigate the fallibility of people and systems. • Describe the ways that every system is designed to achieve the results it gets. • Apply the basic principles of safe design. • Explain the ways that teams make wise decisions with diverse and independent input.

  3. Bilateral Cued Finger Movements

  4. X-Ray Reveals Sponge

  5. A Fatal Mistake: Josie King (18 months old) Died from Medical Error

  6. The Problem Is Large In U.S. health care system: • 7% of patients suffer a medication error. • 44,000 – 98,000 deaths. • 100,000 deaths from HAI. • Patients receive half of recommended therapies. • $50 billion in total costs. Similar results in U.K. and Australia.

  7. A Question • How can this happen? • We need to view the delivery of health care as a science.

  8. How Can We Improve?Understand the Science of Safety • Accept we are fallible — assume things will go wrong rather than right. • Every system is perfectly designed to achieve the results it gets. • Understand principles of safe design: • Standardize. • Create checklists. • Learn when things go wrong. • Recognize these principles apply to technical and teamwork. • Teams make wise decisions when there is diverse and independent input. Caregivers are not to blame.

  9. The Swiss Cheese Analogy

  10. System Factors

  11. A Dosage Error?

  12. Aviation AccidentsPer Million Departures Source: Adapted from Boeing. (2002 June). 2001 statistical summary of commercial jet airplane accidents. Available from: http://www.fearofflying.com/Boeingaccidentstatsum59-01.pdf

  13. Principles of Safety for HITSummary —Lecture a

  14. Principles of Safety for HITReferences — Lecture a — 1 References Boeing. (2002 June). 2001 statistical summary of commercial jet airplane accidents. Available from: http://www.fearofflying.com/Boeingaccidentstatsum59-01.pdf Johns Hopkins Hospital. (2004). Josie King. Available from: http://www.hopkinsmedicine.org/hmn/s04/feature1.cfm Reason, J. (2000). BMJ,320, 768–770. Images Slide 3: Bilateral cued finger movements. Pronovost, P. (2009 February). 10 years after “To Err is Human”: An RCA of Patient Safety Research? Rockville, MD: Agency for Healthcare Research and Quality. Retrieved March 29, 2016, from: http://archive.ahrq.gov/news/events/conference/2008/Pronovost.ppt Slide 4: Sponge left in stomach. Pronovost, P. (2009 February). 10 years after “To Err is Human”: An RCA of Patient Safety Research?Rockville, MD: Agency for Healthcare Research and Quality. Retrieved March 29, 2016, from: http://archive.ahrq.gov/news/events/conference/2008/Pronovost.ppt Slide 5: Josie King. Pronovost, P. (2009 February). 10 years after “To Err is Human”: An RCA of Patient Safety Research?Rockville, MD: Agency for Healthcare Research and Quality. Retrieved March 29, 2016, from: http://archive.ahrq.gov/news/events/conference/2008/Pronovost.ppt

  15. Principles of Safety for HITReferences — Lecture a — 2 Images Slide 9: The Swiss cheese model. Adapted by Dr. Peter Pronovost from original in Reason, J. (2000). BMJ,320, 768–770. Slide presentation from the AHRQ 2008 Annual Conference, September 9, 2008. Slide 10: System factors. Slide presentation from the AHRQ 2008 Annual Conference, September 9, 2008. Image courtesy Dr. Peter Pronovost. Slide 11: A dosage error? Creative Commons by MB Bradford. Available from: http://en.wikipedia.org/wiki/File:Glucagon_vials_and_syringe.JPG Slide 12: Aviation accidents per million departures. Adapted from: Boeing. (2002 June). 2001 statistical summary of commercial jet airplane accidents. Available from: http://www.fearofflying.com/Boeingaccidentstatsum59-01.pdf Slide 13: Josie King. Pronovost, P. (2009 February). 10 years after “To Err is Human”: An RCA of Patient Safety Research?Rockville, MD: Agency for Healthcare Research and Quality. Retrieved March 29, 2016, from: http://archive.ahrq.gov/news/events/conference/2008/Pronovost.ppt

  16. Quality ImprovementPrinciples of Safety for HITLecture a This material (Comp 12 Unit 2) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005.

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