The Science of Improving Patient Safety

1. The Science of Improving Patient Safety Armstrong Institute for Patient Safety and Quality

2. Questions from Past Calls? Armstrong Institute for Patient Safety and Quality

3. Learning Objectives Explain how every system is designed to achieve the results it gets Identify and describe the basic principles of safe design Apply the principles of safe design to technical as well as teamwork Identify how teams make wise decisions when there is diverse and independent input

4. Comprehensive Unit-based Safety Program (CUSP) • Educate staff on science of safety • Identify defects • Assign executive to adopt unit • Learn from one defect per quarter • Implement teamwork tools JtComm J Qual Patient Saf 2010;36:252-60 Resources: http://www.ahrq.gov/cusptoolkit/

5. Targeted Muscle Re-Innervation(courtesy of Dr. Albert Chi) Images courtesy of Dr. Albert Chi, Johns Hopkins Hospital, 2012 1. Nerve Transfers 2. Motor Imagery (3 mo) 3. TMR Prosthetic (6 mo) 4. Sensory functions

6. Postoperative X-Ray Reveals Unwanted Situations http://home.earthlink.net/~radiologist/tf/050800.htm/

7. The Problem is Large • In U.S. Healthcare system • 7% of patients suffer a medication error 1 • On average, every patient admitted to an ICU suffers an adverse event 2,3 • 44,000- 98,000 people die each year as the result of medical errors 4 • Nearly 100,000 deaths from healthcare-associated infections 5 • Estimated 30,000 to 62,000 deaths from CLABSIs 6 • Cost of HAIs is $28-33 billion 7 • 8 countries report similar findings to the U.S. 1.Bates DW, Cullen DJ, Laird N, et al., JAMA,1995 2.Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995. 3. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997. 4. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999. 5. Klevens M, Edwards J, Richards C, et al., PHR, 2007 6. Ending Health Care-Associated Infections, AHRQ, 2009.

8. Preventable Harm in Surgery 230 million surgeries / yr worldwide • More common than births ( 36 million / yr) • 1 in 25 people 25% in-patient surgeries followed by complication • 7 million disabling complications / yr 0.5 – 5% deaths following surgery • 1 million deaths / yr 50% of all hospital adverse events linked to surgery • At least 50% of adverse surgical events are avoidable http://www.who.int/patientsafety/challenge/safe.surgery/en/

9. Surgical Care Improvement Project (SCIP) CMS National Impact Assessment of Medicare Quality Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NationalImpactAssessmentofQualityMeasuresFINAL.PDF. March 2012; 42.

10. Lewis Wardlaw Blackman Image courtesy of Helen Haskell

11. How Can These Errors Happen? • Every system is perfectly designed to achieve the results that it gets • majority of errors don’t belong to individual doctors or nurses • People are fallible • Need to view the delivery of healthcare as a science • Need systems that catch mistakes before they reach the patient

12. It’s a Systems Problem Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects….. Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.” James Reason, Human Error, 1990

13. System Factors Impact Safety Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Adapted from Vincent C, Taylor-Adams S, Stanhope N., BMJ.1998.

14. Case Example • 65 yo M s/p lung resection for cancer • Admit to ICU; discharged to floor on post-op day (POD) 1 • POD 3 develops hypoxia • Admitted to ICU, intubated • CXR shows extensive left lung collapse • Decision to perform broncoscopy

15. System Failure Leading to Error Did not verify equipment availability Fatigue Bronch cart not stocked Patient suffers Communication between resident and nurse Hypoxic arrest

16. Bronchoscopy Adapter Armstrong Institute for Patient Safety and Quality

17. Science of Safety Understand principles of safe design • Standardize, create checklists, learn when things go wrong Recognize these principles apply to technical and team work Teams make wise decisions when there is diverse and independent input Health Services Research, 2006; Circulation.2009;119:330-337

18. Eliminate Steps Johns Hopkins Hospital, 2012.

19. Create Independent Checks Johns Hopkins Hospital, 2012.

20. Healthcare-Associated Infections (HAI): A Preventable Epidemic Focus on 4 HAIs: • VAP, CLABSI, surgical site infections and catheter associated urinary tract infections $5 billion per year excess costs 1.7 million patients per year • 1 out of 20 patients 98,000 deaths per year • As many deaths as breast cancer and HIV/AIDS • 6th leading cause of preventable deaths http://oversight.house.gov/story.asp?id=1865

21. Central Line Associated Blood Stream Infection (CLABSI) Prevention Guidelines for the Prevention of Intravascular Catheter-Related Infections; 2011. www.cdc.gov Mermel LA. Prevention of Intravascular Catheter-related Infections. Ann Intern Med. 2000;132:391-402.

22. Evidence-based Behaviors to Prevent CLABSI Remove Unnecessary Lines Wash Hands Prior to Procedure Use Maximal Barrier Precautions Clean Skin with Chlorhexidine Avoid Femoral Lines MMWR. 2002;51:RR-10

23. Standardize Johns Hopkins Hospital, 2010

24. CLABSI Insertion Checklist • Before the procedure, did they: • Wash hands • Sterilize procedure site • Drape entire patient in a sterile fashion • During the procedure, did they: • Use sterile gloves, mask and sterile gown • Maintain a sterile field • Did all personnel assisting with procedure follow the above precautions • Empowered nursing to stop the procedure if violation occurred Crit Care Med. 2004;32(10):2014.

25. Michigan Keystone ICU N Engl J Med. 2006;355:2725-32; BMJ. 2010;340:c309.

26. Percent of Units with Zero CLABSIs and Achieving Project Goal (<1/1000 CL days) *Data drawn from Interim Project Report – Figure 5 – Cohorts 1 through 3 www.onthecuspstophai.org

27. Improving Care for Ventilated Patients • Semirecumbantpositioning • Peptic ulcer disease and DVT prophylaxis • Appropriate sedation • Daily assessment of readiness to extubate • Oral care with antiseptics Minimize contamination of equipment

28. Improving Care for Ventilated Patients Educate staff Decrease complexity / create redundancy: • Daily goals checklist Other independent redundancies • Nursing and families • Are patients receiving the prevention they should?

29. Sample Daily Goals What needs to be done for the patient to be discharged? What is the patients greatest safety risk? What can we do to reduce the risk? Can any tubes, lines, or drains be removed? J Crit Care. 2003;18(2):71-75

30. Michigan Keystone ICU Infect Control HospEpidemiol. 2011;32(4): 305-314.

31. Principles of Safe Design Apply to Technical and Teamwork

32. Communication Breakdowns Communication breakdowns are frequently the root cause of… undesirable outcomes

33. Basic Components and Process of Communication Elizabeth Dayton, Joint Commission Journal. Jan. 2007

34. Teams Make Wise Decisions When There is Diverse and Independent Input Wisdom of Crowds Redundancy is two sets of eyes trained differently looking at same picture Structured communication tools linked to improved patient outcomes

35. Briefings and Debriefings • Reductions in communication breakdowns and OR delays 1 • Reductions in procedure and miscommunication-related disruptions and nursing time spent in core 2 • Improved communication and teamwork, feasible given current workload 3 • Reductions in rate of any complications, SSI and mortality 4 1 Arch Surg. 2008;143(11): 1068-1072. 2 J Am Coll Surg. 2009;208:1115-1123. 3 JtComm J QualSaf. 2009;35(8):391-397. 4 N Engl J Med. 2009;360:491-9.

36. Conclusion: 74 VHA facilities in team training program, including implementation of briefings and debriefings experienced an 18% reduction in annual mortality compared with a 7% decrease among the 34 VHA facilities that had not yet undergone training. JAMA. 2010;304(15):1693-1700

37. Summary Safety is a property of systems • Standardize, create checklists, learn when things go wrong • We need lenses to see the system Recognize these principles apply to technical and team work Teams make wise decisions when there is diverse and independent input

38. Lewis Wardlaw Blackman Image courtesy of Helen Haskell

39. Action Items Have all staff, unit leadership and executive leadersview the Science of Improving Patient Safety video Put together a roster of who needs to view the Science of Safety video, establish a timeline for completion and track progress

40. Comprehensive Unit-based Safety Program (CUSP) • Educate staff on science of safety • Identify defects • Assign executive to adopt unit • Learn from one defect per quarter • Implement teamwork tools JtComm J Qual Patient Saf 2010;36:252-60 Resources: http://www.ahrq.gov/cusptoolkit/

41. On-boarding Call Evaluation We want to ensure that the on-boarding calls provide useful and pertinent information for the SUSP teams. For this reason we request that you complete a brief evaluation following each call. The evaluation may be found at the following link: • https://www.research.net/s/susp_cohort_3 If you are not able to reach the link from the slide, please cut & past the URL into your browser. Armstrong Institute for Patient Safety and Quality