Casting the Safety Net Fish or Cut Bait Capturing Precursor Safety Events

1. Casting the Safety Net � Fish or Cut Bait?  Capturing Precursor Safety Events Indiana Association for Healthcare Quality 2010 Annual Conference April 30, 2010

2. Martha Boutin White, RN, BSN, MBA, Patient Safety Officer Memorial University Medical Center Savannah, GA Sherry L. Sweek, RHIA, CPHQ, CPMSM, Director of Quality Improvement Southeast Georgia Health System Brunswick, GA

3. Objectives Define Precursor Safety Events including errors of omission Explain leverage points introduced to increase reporting and decrease errors Share results and data analysis Review lessons learned Discuss next steps and recommendations

4. Overview Memorial�s safety journey 2008 Safety refocus Precursor safety events project How we got started Problems we encountered Current safety performance Next steps

6. Memorial University Medical Center Two-state healthcare organization servicing a 35-county area in southeast Georgia and southern South Carolina Four-year medical school on campus affiliated with Mercer University School of Medicine 530-bed tertiary hospital with Core Services: Level 1 Trauma Center Level 3 Neonatal Intensive Care Nursery Heart & Vascular Institute Curtis & Elizabeth Anderson Cancer Institute George & Marie Backus Children�s Hospital Rehabilitation Institute

7. Off Course: An Alarming Trend in 2002

8. Gaining Direction in Our Safety Journey Conducted Mandatory Error Prevention Training (Team Members, Team Leaders and Physicians) Enhanced Analysis of Events (Root Cause / Common Cause) Established and Enforced �RED Rules� for Operating Room, Invasive Procedures, and overall Hospital Global �RED Rules� Implemented Incident Scoring System (Compliance & Patient Outcome) Incorporated Increased Reporting Metric (ROSI) in Team Leader Bonus Structure Created Safety Coach Program and Dedicated FTE Positions Beyond this training other initiatives are being employed to improve patient safety. They include.....Beyond this training other initiatives are being employed to improve patient safety. They include.....

9. We Thought We Had The Right Course

10. Straying Off Course: 2006-2007 Dealt with OIG Investigation for Alleged Stark Violations and 22 surveys in an 18 month time period Observed 31% Decreased Incident Reporting Discounted Increased Sentinel Events Due to Joint Commission Definition Changes Failed to Recognize System Wide Issues and Implement Changes Experienced Instability with Loss of Patient Safety Officer, COO, CNO, CFO, Director of Quality, VP of Quality and Patient Safety Moved Away from Safety to Financial Situations by All Leaders Not Cognizant of the Impact of Financial Woes on Safety Beyond this training other initiatives are being employed to improve patient safety. They include.....Beyond this training other initiatives are being employed to improve patient safety. They include.....

12. When Did We Fish?

14. Total Time to Complete a Root Cause Analysis Determination of SSE � 6�8 hours (x2) Communicating to stakeholders - 6 Charter � 1 hour Interviews � 1 hour each (x10x3) Swiss Cheese diagram � 1 hours Task Analysis � 3 hours Event Time Line � 2 hours (x2) Team Meetings � 2.5 hours each (x8x3) Report Completion � 2 hours Pre-report with Champion � 1 hour (x3) Presentation of Report � 1.5 hours (x4) Coding the event in database � 1 hour Total: 133 hours/month Total spent by Risk Management � 8+10+2+7.5+1+1.5=30 Quality � 8+6+1+10+1+3+2+7.5+2+1+1.5+1= 41.5 Other team members � 10+(7.5x6=45)+1+1.5+1.5= 59Total spent by Risk Management � 8+10+2+7.5+1+1.5=30 Quality � 8+6+1+10+1+3+2+7.5+2+1+1.5+1= 41.5 Other team members � 10+(7.5x6=45)+1+1.5+1.5= 59

15. �We�re gonna know all there is to know about the PSE business�

17. What is a Precursor Safety Event? A precursor safety event is a variation in care that reaches the patient but does not cause permanent harm Delay in treatment Failure to recognize Improper Pt ID Inadequate check Inadequate handoff Inadequate monitoring Missed medication Missed treatment Omitted Action Wrong dose Wrong medication given Wrong treatment Most people talk about variation in care that reaches pt. These are variations that don�t reach patient. We consider that omitting things also causes problems. If a pt came in, we did nothing to them and they died, wouldn�t we have a SSE?Most people talk about variation in care that reaches pt. These are variations that don�t reach patient. We consider that omitting things also causes problems. If a pt came in, we did nothing to them and they died, wouldn�t we have a SSE?

19. Did We Have the Right Equipment? License � Approval of Quality & Patient Safety Committee and Board of Directors to fish for PSEs Net � Decree to increasing the number of incident reports became a strategic objective Bait � Rewards for Safety Saves Catch � Precursor Safety Events with coded information to drive improvement

20. We Bought a Trawler...on Credit Is no money for safety � that is soft green money. That $million we get for safety? The check is in the mail.Is no money for safety � that is soft green money. That $million we get for safety? The check is in the mail.

21. We Pulled Up Full Nets 2009: 8,509 incidents, 2 Serious Safety Events 709 incidents per month 210 incidents per month visitor issues, workers comp or physician complaints 144 incidents per month near misses 355 PSEs per month Everyone gets to eat�. Volume really gets people worked up!!!!! WE DO NOT HAVE 343 FISHING POLES!!!Volume really gets people worked up!!!!! WE DO NOT HAVE 343 FISHING POLES!!!

22. Beware of Shifting Tides Fishy Headlines Paradigm Shift Required Risk Management Shares Information and Promotes Transparency No Compass on How to Navigate Internal Sonar Better Than Nothing

23. Risk Throws in a Flotation Device Began Weekly Meeting with Risk Review Precursor Safety Events Verify Profession Involved Define Inappropriate Act Determine Apparent Cause Reports Code Completed A/C reports Review Safety Saves for PSEs Last 3-4 hours Process of PSE data management is cumbersome and time consuming Last 3-4 hours Process of PSE data management is cumbersome and time consuming

24. Back on Dry Land� Assign Apparent Cause Reports in Safety Database Have Management Engineers Customize Database to House PSE information Compile Safety Saves and Produce Certificates

25. What�s Our Catch?

26. Is It a Keeper? WHEN I HAD FINISHED, I BROUGHT pt. N WAS NO LONGER WITH PT AND PT WAS NOT MONITORED. PT INITIALLY CAME TO ER FOR TRAUMA TO FACE/HEAD FROM FALL. PT WAS NOT AWAKE, OR COMMUNICATIVE WITH ME WHEN I BROUGHT HER TO THE SCANNER. I WAS ABOUT TO GET ASSISTANCE WITH MOVING THE PT WHEN SHE coded

27. We Fish, They Feast Generated Department Specific PSE Report Included PSE Reports to Senior Leadership Rounds Send PSE Reports to Managers, Directors and Safety Coaches Modified PSE Report Format to Incorporate Voice of Customer

29. Man Overboard!!! Hard to Stay the Course When Everyone Wants to Change Direction Teach Them to Fish, Teach Them to Fish, Teach Them to Fish Safety Drills Swiss Cheese of Errors Reinforce Error Prevention Techniques Required Actions from Senior Leadership, Directors, Managers Firefighters � fix everything immediately Man overboard � explain and reexplain as we change Safety drills � safety standdown based on 4 serious events in 10 days � no nurse x 12 hours; pressure ulcer charting; blood to wrong patient; wrong pt id in time outFirefighters � fix everything immediately Man overboard � explain and reexplain as we change Safety drills � safety standdown based on 4 serious events in 10 days � no nurse x 12 hours; pressure ulcer charting; blood to wrong patient; wrong pt id in time out

30. I Caught a Fish This BIG� Added PSE to Monthly Dashboard Established Procedure for Accountability for Apparent Causes Completion Determined Frequency of PSE Report to Quality Oversight Committee and Board of Directors Conducted and Presented Common Cause Analysis Based on PSE Data

31. My Fish is Bigger Than That Safety Rounding Tool Modified Each Month Based on Data from PSEs STAR (Stop, think, act, review) Safety Huddles Patient Identification Pre Rounding Huddle for Unit Specific Trend or Unresolved Issues Behavior Based Monitoring Compliance Included on Report and in Dashboard

32. We Confirm Tears in The Nets

33. Looking First for Tears in The Net Included data from October 2008 through May 2009 Data used to generate reports for Patient Safety Rounds 734 Precursor Safety Events 869 Inappropriate Acts Majority of Inappropriate Acts are committed by �Sharp End� care givers All PSE�s coded based on event description and additional investigation emphasizing coding data from: Apparent Cause Reports Level 1 or Level 2 PSEs (temporary or minor harm) 70% of PSEs only partially coded due to incomplete information

34. Total number of PSEs did not decrease. PSE reporting has remained consistently within 5%. Total number of PSEs did not decrease. PSE reporting has remained consistently within 5%.

37. The Radar Suggests� Sharp End Employees are Identified Most Often in Committing Inappropriate Acts RNs, Pharmacists and Physicians Common Threads Among all Professional groups S.T.A.R. (Stop, Think, Act, and Review) Rule Based Errors (Patient ID Error) Limitations of The Data Self-reported Incomplete Data Some Areas Still Perceive Reporting as Punitive

41. STAR as an Effective Error Prevention Tool � High Risk Areas Do this in a bar chart�Do this in a bar chart�

42. Mending the Nets

43. Charting the Course Formed Two Ad-Hoc Teams on: Integrating S.T.A.R. into Patient Safety Practice Maximizing Report Quality in MAXPI Team Initiatives Included on Top Ten List Team Skippers were CNO and CFO Development Center � Team Facilitation Team Recommendation to Quality Oversight Committee with Implementation Plan

44. Stay Within the Bouys Added Precursor Safety Events Goals to Safety Improvement Plan Included PSE Metrics on Monthly Dashboard Reported PSE Trends Quarterly to Quality Oversight Committee and Board Conducted annual PSE Common Cause Analysis

45. 2009 Common Cause Navigation 1102 Precursor Safety Events 1310 Inappropriate Acts 17.5% of PSEs with Temporary or Minor Harm Results Mirror Common Cause from August 2009 Five Straight Months with 100% of Apparent Cause Reports Completed in Two Weeks 35%-45% of Inappropriate Acts are with Medication Nutrition Process 50% of Inappropriate Acts could have been Prevented by Using STAR

46. Precursor Safety Event Severity

47. PSE Error Categories

48. PSE Professional Group

49. PSE Error Prevention Techniques

50. S.T.A.R - RN

51. S.T.A.R - Pharmacy

52. S.T.A.R � M.D.�s 9 of 33 Coordinating were issues with 9 of 33 Coordinating were issues with

53. Casting the Safety Net Obtaining Right Incident Information Up Front a Challenge Identifying PSEs Easier Said than Done Moving Between Risk & Quality Databases Cumbersome Preparing Leadership for the Number of PSEs is Important Taking Action on PSE Data is Key to Making Gains on Patient Safety

54. Our Goal: Catch Error Before Patient Harm

55. Are We Catching Any Fish?

56. Insert the chart

57. 2010 Safety Goal Event Free Calendar 250 Days

58. Navigating in New Waters� Completed a Business Case for Safety 68% decrease in cost of completing root cause investigations and savings of over $100,000 Costs associated with payouts and write-offs decreased by 90% and savings of over $400,000 More staff time to fish because we were not spending time and effort on reactive steps for safety Managers able to spend time on Precursor Safety Events

59. �That�s all I have to say about that��

60. Sherry Sweek Southeast Georgia Health System 2450 Parkwood Drive Brunswick, GA 31520 912.466.2124 ssweek@sghs.org Martha White Memorial University Medical Center 4750 Waters Ave, Suite 451 Savannah, GA 31404 912.350.7569 whitema2@memorialhealth.com Contact Information