CNL Impact on Patient Safety

1. CNL Impact on Patient Safety Patient Safety Patient Involvement Human Factors Engineering

2. The Origin of the VA Patient Safety Improvement Program • VA (VHA) identified patient safety as a high priority issue in 1997 • 1999 VA National Center for Patient Safety • 1999 IOM report, To Err is Human caught the attention of the country

3. Veterans Health AdministrationPatient Safety Program

4. Patient Safety – The Problem is Not New 1964 - Schimmel(Ann. Int. Med.) • 20% of Univ. Hospital Admissions Injured • 20% of those serious/fatal 1981 - Steel(NEJM) • 36% of Teaching Hosp. Admissions Injured • 25% serious or life threatening 1989 - Gopher(Proc. Human Factors Society) • 1.7 errors/day/patient (29% pot. serious)

5. Patient Safety – The Problem is Not New 1991 - Harvard Practice Study(NEJM) • 4% of Admissions Injured • approx. 0.5% fatal 1995 - Family Practice MDs(JFamPrct) • approx. 50% committed error resulting in patient death 11/99 - IOM Report • Deaths due to Preventable Adverse Events greater than, MVA, Breast Cancer, or AIDS

6. THE "MISHAP PYRAMID" Type A Severity Type B Type C Frequency Incidents Close Calls Strong Program Model Patient Safety System Design

7. Close Calls Have Value in Safety Close calls can provide “sentinel” information before a “reviewable sentinel event” occurs.

8. Patient Safety – We need a learning system • Reporting system • encourage more and accurate reports • remove fear • demonstrate the benefit • Use a systems approach • Solutions must be user-centered

9. Patient Safety – We need a learning system • Appropriate view of blameworthy behavior • Intentionally Unsafe Acts An “intentionally unsafe act” is defined as “a criminal act; a purposefully unsafe act; an act related to alcohol or substance abuse by an impaired provider and/or staff; or events involving alleged or suspected patient abuse of any kind.”

10. VHA Patient Safety Lessons Learned • Cannot mandate culture change – support must be won • Communication is the key • Personal, not e-mail • Top leadership must maintain the drumbeat • Target upper and middle management first

11. VHA Patient Safety Lessons Learned • Design systems to suit the needs of the front-line as the first priority • Design the glove to fit the hand, not the hand to fit the glove • Actions must demonstrate that patient safety is a real priority, not just an official priority • Safety related duties can’t be an afterthought or collateral duty

12. Patient Safety Core Concepts • Goal is to reduce patient harm • Counting reports is not the objective • Uncharted territory • Cultural change is the key • Prevention NOT Punishment

13. http://www.patientsafety.gov

14. The Daily Plan

15. We Wondered • … would patients question if something seemed different than planned? • …could errors of omission and commission be noticed and prevented? 3. …would the patient be more comfortable asking questions after receiving a written summary?

17. Pilot Tested • Addressed confidentiality issues • Completed Pilot Phase I • Five VA med/surg units winter 07/08 • Nurses evaluated it • Patients evaluated it

18. The Daily Plan Pilot Results • Number of patients: 109 • Days in hospital: • Mean = 4.4 SD = 3.3 • Days receiving Daily Plan: • Mean = 2.2 SD = 1.8 • 76% of the surveys were completed by the patient • 5% completed by the family • 6% completed by both

19. The Daily Plan Pilot Results

20. The Daily Plan Pilot Results

21. Staff Evaluations • Nurses with patients involved completed one evaluation at the end of the shift. • A single evaluation represented all their patients receiving Daily Plans that shift. • Number of Staff Evaluations = 92 • Percentages rounded to whole numbers for this presentation

22. Nurses’ Feedback End-of-shift evaluation • By utilizing The Daily Plan with patients today, please indicate how many times you corrected things that were missing from the orders; these would be defined as apparent errors of omission. • Mean = 0.67 SD =1.20 • 35% reported at least one incident

23. Nurses’ Feedback End-of-shift evaluation • By utilizing the Daily Plan with patients today, please indicate how many times you and/or the patient noticed and corrected something which prevented a possible medical error. • Mean = 0.30 SD = 0.74 • 21% reported at least one incident

24. Nurses’ Feedback End-of-shift evaluation • The Daily Plan created an opportunity for me to provide education to patients and/or family today, please select the number: • Mean = 1.89 SD = 1.82 • 66% reported at least one opportunity

25. Next Steps Patient-friendly language Larger print/font Include more information

26. Making Things Better Human Factors Engineering

27. Objectives Describe how human factors engineering can be used to support patient safety Apply human factors engineering concepts to patient care

28. Human Factors Engineering • How we function as humans • How we think • How we learn • How we problem solve • See, hear, smell, taste, feel • Communication styles • Ranges in physical size and strength, etc.

29. What is Human Factors Engineering (HFE)? HFE is the basic science that underlies patient safety Engineering the world to fit the way humans work Using methods to uncover hidden needs and unexpected interactions Taking advantage of knowledge bases about human-system interaction Designing the glove to fit the hand rather than the hand to fit the glove.

30. Human Factors Engineering Psychomotor - Hand - Eye movements • Input Devices • Keyboard -Voice recognition Interface Senses - Vision - Hearing Output - CRT - Sound

31. Could there be a better design? • positioning your hands in an automated sink so the water keeps flowing • pushing the wrong button • closing the wrong window in a computer program

32. Human Factors Engineering-A Broad Impact • Aviation (since 1940’s) • Nuclear power • Space flight • Computer software and hardware • Consumer products • palm pilot, snakelight

33. Paired Learning Pharmacist uses Enter button 95% of time to enter data Pharmacist uses Spacebar5% of time to enter data

34. How good are we at vigilance/paying attention?

35. Performance Graph 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

36. Performance over time 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

37. How could we improve performance? 100% 90% 80% 70% Performance 1 2 3 4 Time (hours)

38. Human Vigilance

39. Basketball Video • Count the number of passes made between basketball players wearing white • Bounce pass or person to person • Write down your answer • At the end, I will ask for your answers

42. Inattentional blindness

43. Demonstration: Stroop Test Row 1 Row 2 Row 3

44. Now, state the color of the TEXT …as fast as you can… Green Yellow Red Blue Row 1 Green Yellow Blue Red Row 2 Green Red Yellow Blue Row 3

45. Again, state the color of the TEXT …as fast as you can… Red Blue Green Yellow Row 1 Yellow Green Blue Red Row 2 Green Yellow Blue Row 3 Red

46. It’s almost impossible to ignore colorAir or oxygen?

47. Three different items

48. We cannot ignore color We must read labels Note: Color matching may be helpful in some situations

49. The Normalization of Complexity We enjoy it Healthcare workers compensate for complex, unclear workplaces and devices Mastery of the complex becomes a normal strategy Without regard to reasonableness or necessity of complexity

50. Normalization of Complexity