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Quality and Patient Safety

Quality and Patient Safety. Handoffs Emily Carr Collaboration Project . How Hazardous is Healthcare ?. Dangerous (>1/1000). Regulated. Ultra-safe (<1/100K). 100,000. Health Care. Driving. 10,000. Total Lives Lost per year. 1,000. Scheduled Airlines. Chartered Flights.

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Quality and Patient Safety

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  1. Quality and Patient Safety Handoffs Emily Carr Collaboration Project

  2. How Hazardous is Healthcare? Dangerous(>1/1000) Regulated Ultra-safe (<1/100K) 100,000 HealthCare Driving 10,000 Total Lives Lost per year 1,000 Scheduled Airlines Chartered Flights Mountain Climbing 100 European Railways Bungee Jumping Chemical Manufacturing 10 Nuclear Power 100,000 1,000,000 10 1 10,000 10,000,000 100 1,000 Number of encounters for each fatality

  3. To Err is Human/IOM Report Estimated that 44,000 to 98,000 Americans die each year as a result of adverse events. Adverse events result from system error rather than poor performance or purposefully harmful individuals.(Sharpe, 2003)

  4. CIHI Report -2004 Canadian National Study that analyzed 3745 charts 7.5% hospitalized patients experience an adverse event 2/3 AE resulted in temp. disability and the other 1/3 were more serious even deaths. Potentially 9,000-24,000 deaths annually due to adverse events.

  5. 1% Error Rate (American Stats): 3 jumbo jet crashes every 2 days 16,000 pieces of lost mail every hour

  6. 1% Error Rate 32,000 bank cheques deducted from the wrong account every hour. If we accepted 0.1% that would mean; 99.9% = 2 unsafe landings at O’Hare daily. (Deming 1987)

  7. Steps to Improve Safety Basic Tenets of Human Error Everyone commits errors Human error is generally the result of circumstances that are beyond the conscious control of those committing the errors Systems or processes that depend on perfect human performance are fatally flawed Brown-Spath

  8. Process Redesign Solutions Design safer processes Barriers or safeguards can prevent untoward events X-ray confirmation of tube placement Mandatory repeat-backs (Starbucks) Door alarms Surgical site confirmation Brown-Spath

  9. The System in Action…* 133 People to take care of the Patient The Patient * The Safer Patient Initiative, North Wales, UK

  10. Some Examples

  11. Human Factors

  12. Medication Safety Illegible Handwriting Look Alike/Sound Alike (Cerebrex, Celebrex) Unsafe Abbreviations Unsafe High-Risk Medications Verbal Order Read Back (Starbucks!)

  13. Packaging

  14. Communication Some examples of strategies are: Surgical Safety Checklist SBAR Handoffs Shift Reports

  15. Safety Checklists Communication tools to empower teams by increasing situational awareness, teamwork and cooperation, problem-solving and decision-making, and leadership and management in complex environments Many industries: Aviation and Aerospace, Energy (hydro, nuclear, petro-chemical), Heavy Construction Military

  16. Surgical Team in Action

  17. SBAR Situation – what is the problem? Background – pertinent information to problem at hand Assessment – clinical staff’s assessment Recommendation – what do you want done and/or think needs to be done? (hardest for RNs to do)

  18. What do we mean by handoffs? • Situations where information is passed from one caregiver to another • Between individuals, teams, departments • Different times of day and varying situations

  19. Shift Reports • Reports between nurses at shift change: • Variety of different methods • Tapes, verbal, written notes, etc.

  20. Some examples • Youtube: http://www.youtube.com/watch?v=zw5cy8yoEbs&feature=related • http://www.youtube.com/watch?v=N-Xy-gbVbXk&feature=related • http://www.youtube.com/watch?v=cyOAEcMgo3c&feature=related • http://www.youtube.com/watch?v=e0mYe14UbVA&feature=related http://www.youtube.com/watch?v=NOKDrWyYM6I&feature=related

  21. Your Challenge • Design an innovative strategy to improve shift-to-shift report for a variety of different nursing areas that: • Improves communication • Efficient • Timely • Incorporates appropriate information to safety hand patient over to next shift

  22. Questions?

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