Prepared For : National Patient Safety Foundation: Stand Up for Patient Safety program

1. Sharing and Learning: How to Use Patient Safety Morbidity & Mortality Conferences to Achieve Transparency and Promote a Culture of Safety Prepared For : National Patient Safety Foundation: Stand Up for Patient Safety program March 19, 2008 Presented By: Cynthia Barnard, MBA, MSJS, CPHQ Marilyn Szekendi, PhD, RN

2. Our Discussion will Cover . . . • The Goal: A Culture of Safety • The Patient Safety Morbidity & Mortality Conferences • How to: • Design • Implement • Use the findings • Evaluate

3. Northwestern Memorial HospitalChicago, Illinois • 800+-bed Academic Medical Center • Nationally Recognized for Clinical Excellence • Strong Tradition of Community Service • Major Employer in City of Chicago • New World-Class Facility Opened in 1999 • One of Two U.S. Hospitals with an AA+ Bond Rating

4. Key Northwestern Memorial Hospital StatisticsFiscal Year 2007 • Inpatient Admissions 43,855 • Patient Days 209,629 • Average Daily Census 591.9 • Average Length of Stay 4.78 days • Deliveries 10,538 • Hospital Outpatient Registrations 477,065 • Surgical Cases – Inpatient 12,137 • Surgical Cases – Outpatient 18,758 • Emergency Department Visits 76,701 • Beds 744* • Medical Staff 1,545 • Employees 6,962 * The number of beds increased to 897 with the opening of the new Prentice Women’s Hospital on October 20, 2007.

5. Pursuing a Culture of Safety

6. What does a culture of safety look like? • Organizational commitment to create and support safe systems • Environment in which individuals feel free to • identify errors • openly question the safety of existing systems, and • constructively analyze problems • Errors are used for learning and for improving • Hierarchies are flattened • Transparency at all levels is encouraged Dana-Farber Cancer Institute Principles of a Fair and Just Culture, Dana-Farber Cancer Institute, accessed at www.dana-farber.org/abo/news/tools/justculture.asp.

7. Who creates and exhibits a culture of safety? • The environment for the culture is created by organizational leadership, which provides the atmosphere and opportunities for learning from error • The culture is adopted by staff members at all levels of the organization, who respond to and benefit from the created environment Wilkins BA. (2004). A brief summary of concepts from nuclear energy’s work to develop a safety culture. Inova Health System.

8. High Reliability Organizations • Preoccupation with failure • Reluctance to simplify interpretations • Sensitivity to operations • Commitment to resilience • Deference to expertise Weick KE & Sutcliffe KM (2001). Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco: Jossey-Bass.

9. How Do You Know Whether You Have a Culture of Safety? • Incident reporting • Interdisciplinary collaboration • Walk Rounds • Collegial rapid improvement projects • Metrics such as AHRQ Hospital Survey on Patient Safety Culture (HSOPSC)

10. National Challenges in Culture of Safety AHRQ Hospital Survey on Patient Safety Culture (HSOPSC) National Data: 382 hospitals and 108,621 hospital staff respondents • Highest scores for Teamwork Within Unit • Lowest scores for Nonpunitive Response to Error: “the lowest average percent positive response (43 percent), indicating this is an area with potential for improvement for most hospitals….” • “The survey item with the lowest average percent positive response (35 percent) was: "Staff worry that mistakes they make are kept in their personnel file" (an average of only 35 percent strongly disagreed or disagreed with this item). “ Hospital Survey on Patient Safety Culture: 2007 Comparative Database Report http://www.ahrq.gov/qual/hospsurveydb/hospdbch5.htm

11. How can we promote and support a culture of safety?For example . . . • Create structure for the systematic review of safety concerns • Establish care delivery practices that encourage teamwork and collegial relationships among members of different disciplines • Institute human resource policies that support a non-punitive culture • Create vehicles for sharing and learning from errors

12. Patient Safety Morbidity & Mortality Conference

13. Patient Safety M&M • Created in 2003 to • Openly identify and examine errors that occur in our hospital • Perform a retrospective analysis (root cause analysis) with an interdisciplinary group • Bring members of all disciplines together to share information and problem-solving efforts • Bring lessons learned and solutions back to M&M participants • Encourage further event reporting

14. Introducing the Idea and Initiating the Conference • Identify needed champions • Ensure agreement on goals and process from other interested departments (e.g., Risk Management, Medicine, Nursing, Pharmacy) • Establish organizational coverage for the M&Ms to maintain their status as quality initiatives according to your state law • Identify needed resources (e.g., personnel for planning, meeting space, time allotment for staff to attend/complete)

15. Patient Safety M&Ms: Two Forums, Two Audiences 1. Interdisciplinary Patient Safety M&M • Monthly live conference, beginning at noon for one hour in large conference room that can seat up to 100 people • Notice of conference sent via email each month; interesting title • Lunch served to attendees • Nursing contact hours and ACCME credits for physicians offered for each program 2. Nursing Patient Safety M&M • Monthly online module completed by staff nurses • Case study directly related to nursing care

16. Interdisciplinary M&M Monthly Meeting

17. Interdisciplinary Patient Safety M&MProgram Organization • Case study selected each month based on • High priority recent events reported via incident reporting system • Other events related to ongoing clinical care / safety initiatives within the organization (e.g., falls, medication reconciliation, handoffs) • On occasion, an event that occurred elsewhere, but could have happened at our hospital • Panel is selected for each conference • Panel members represent the disciplines involved in the actual event • Typically physician, nurse, pharmacist • May or may not have been actually involved in the event

18. Program Agenda 1.Closing the Loop on Previous M&M Findings • Program begins with review of prior month’s case with key findings and recommendations from the M&M participants 2. Presentation of Case Study The case is read; all audience members have a hard copy for reference.

19. Program Agenda 3. Discussion, Root Cause Analysis (VA National Center for Patient Safety model), and Plan for Improvement VA Root Cause Framework • Human Factors – Communication • Human Factors – Training • Human Factors – Fatigue/Scheduling • Environment/Equipment • Rules/Policies/Procedures • Effective Barriers/Controls to Protect Patient Safety

20. Example Interdisciplinary M&M

21. Sample M&M: Follow Up From Prior Month

22. Sample M&M: Case Study for This Month JW is a 42 year old female who presented to the Emergency Department on 7-10-07 with complaints of fever, chills, right flank pain, and pain on urination. She was diagnosed with pyelonephritis, given a first dose of intravenous ciprofloxacin in the Emergency Department at 0100 on 7-11, and admitted for continuation of intravenous antibiotics. The order for intravenous ciprofloxacin was placed as a “pharmacy to dose” order by the admitting physician. The order was verified by the pharmacist, but a dosed order was never entered. On the following day, 7-12, the patient complained of increasing abdominal pain so a CT scan was completed which revealed pyelonephritis. It was then discovered that the patient had not received any intravenous ciprofloxacin since the first dose in the Emergency Department. She received her second dose at 1800 that day (7-12), 41 hours after her first dose. Her pain improved and her white blood cell count began to fall. She was discharged home two days later.

23. Sample M&M: Case Study Discussion Guide Triage Questions • Were issues related to patient assessmenta factor in this situation? • Were issues related to staff training or staff competency a factor in this event? • Was equipment involved in this event in any way? • Was a lack of information or misinterpretation a factor in this event? • Was communication a factor in this event? • Were appropriate rules/policies/procedures – or the lack thereof – a factor in this event? • Was the failure of a barrier designed to protect the patient, staff, equipment, or environment a factor in this event?

24. Sample M&M: Case Study Discussion Guide Focus on the following six categories • Human Factors – Communication • Human Factors – Training • Human Factors – Fatigue/Scheduling • Environment/Equipment • Rules/Policies/Procedures • Effective Barriers/Controls to Protect Patient Safety

25. Interdisciplinary M&M – Evaluation

26. Nursing Online M&M

27. Nursing M&MProgram Organization • Case study selected each month based on • Relevance to nursing practice • High priority recently reported events • Other events related to ongoing clinical care / safety initiatives within the organization (e.g., medication administration) • On occasion, an event that occurred elsewhere, but could have happened at our hospital • Online PowerPoint module created and posted online • Nurses complete on their own • Managers have 85% completion goal for their staff

28. Example Nursing M&M Module

29. NMH Patient Care Division Picture is for illustration purpose only Patient Safety Morbidity/Mortality Study Module Patient Identification November 2007 Exit

30. Upon Completion . . . Participants will be able to: • Identify the importance of performing a thorough and accurate identification of any patient prior to providing any patient care service. • State the required components of the patient identification process. • Describe the unintended consequences of incorrect patient identification. • Explain methods for improving patient identification procedures in their area of practice.

31. Accurate Patient Identification The accurate identification of patients prior to the provision of care – particularly the administration of medications or the performance of any invasive procedures – is an important role of professional nurses in caring and advocating for their patients. Picture is for illustration purpose only

32. Case Study #1 Ray Williams*, a 53 year old male, was scheduled for a paracentesis in Interventional Radiology (IR) on 09-04-07. When the IR staff were ready to have the patient transported, they selected the name of another patient, Roy Williams, in the teletracking system. The transporter received the request for Roy Williams and picked him up and transported him to IR for the procedure. Picture is for illustration purpose only Roy Williams arrived in IR. In the holding area, a nurse discovered that he was not the patient scheduled for the procedure and he was returned to his room. Mr. Williams was angry and frightened by the error. *All names have been changed.

33. Case Review 1.In case study #1, at what point(s) in the process were there errors or lapses in patient identification? A. Requesting the patient in the transport teletracking system B. Correct patient identification by the transporter in the patient’s room C. Identification of the patient by the transporter and the patient’s nurse on the inpatient unit (handoff) D. Identification of the patient by staff in the IR holding area E. A and C F. All of the above

34. Case Review • Great Job! • In this case, the incorrect identification of the patient began when the IR staff selected the wrong patient name in the transport tracking system. The error continued unrecognized because the transporter and nurse on the inpatient unit had no communication prior to the patient being picked up and taken to IR. Had the nurse been contacted, she would have recognized that the patient being picked up was not scheduled for an IR procedure on that day.

35. Case Review • Incorrect. The correct answer is . . . • A and C. In this case, the incorrect identification of the patient began when the IR staff selected the wrong patient name in the transport tracking system. The error continued unrecognized because the transporter and nurse on the inpatient unit had no communication prior to the patient being picked up and taken to IR. Had the nurse been contacted, she would have recognized that the patient being picked up was not scheduled for an IR procedure on that day. • The transporter correctly identified the patient in his room and the nurse in the IR holding area also correctly identified the patient, leading to the discovery of the error.

36. Nursing M&M – Evaluation • Online survey conducted to obtain nurses’ assessment of Nursing M&M • Survey items taken from AHRQ HSOPSC survey • 307 nurses responded, representing full range of clinical areas – February – March 2008 • Responses compared to hospital-wide HSOPSC culture survey responses for 716 nurses from May 2006

37. Nursing M&M Survey Results

38. Nursing M&M Survey Results

39. Nursing Feedback on M&M Program Many positive comments, but some constructive criticism as well • Nurses in Neonatal Intensive Care Unit and obstetrics brought to our attention that • “Scenarios are never geared towards maternal-fetal medicine.” • “I feel like they never pertain to our unit.” • “Would like to see some more neonatal specific, rather than adult based.”

40. Nursing Feedback on M&M Program • Some nurses preferred the original format, which involved case presentation and discussion at a staff meeting • “I think it was more beneficial when they were done by the manager.” • “I like the way we used to do M&Ms, which was discussing as a group during staff meetings.”

41. Nursing Feedback on M&M • Favorable responses overall • “It is truly an eye opener to learn how mistakes are made and how NMH has come up with many safety tools and policies to prevent them.” • “It is important to learn from actual cases that occur here at NMH and the M&Ms mostly help as refreshers to how we should be practicing and hopefully change people's bad habits.” • “I think that it is a great idea to learn from mistakes that did occur. This teaches staff that it is human to err.”

42. Summary • Patient Safety M&Ms have contributed to the creation of a culture of safety at Northwestern Memorial Hospital and have provided a valuable forum for the sharing of experiences, ideas, and problem solving among clinicians of multiple disciplines. • We will continue to “reinvent” both programs based on feedback from participants to maximize the programs’ usefulness for providers.

43. Questions / Discussion