The Impact of Medical Errors

1. The Impact of Medical Errors

2. Two Boeing 747s, operated by KLM and Pan Am, collide due to breakdowns in communication and safety checks. Number of people killed: 583 Diane Brack

3. This plane flew in a holding pattern for 77 minutes while awaiting landing clearance at JFK and crashed due to a failure to communicate the urgency of fuel situation. Number of people killed: 73

4. As many as 98,000 deaths occur as a result of medical errors each year

5. That’s the same as a 747 jet falling out of the sky EVERYDAY for a YEAR!!!

6. More Americans die from medical errors than from breast cancer, AIDS, or car accidents combined

7. 22,980 Obstetrical adverse events every year are caused by medical error

8. Cost associated with medical errors is $8–29 billion annually

9. Failures in Communication are the leading contributor to sentinel events. ~The Joint Commision

10. Communication Failures contributeto 72% of Root Cause Analysis of sentinel events in perinatal units

11. The solution?

12. Strategies and Tools to Enhance Performance and Patient Safety ™

13. CHAIN EXERCISE 13 13

14. Using the materials in front of you, create a paper chain with the most links. You may only use your non-dominant hand. You have 2 minutes to create this chain.

15. Objectives • Road To TeamSTEPPS • TeamSTEPPS Concepts and Tools • Impact on Culture of Safety • The Journey Continues…

16. The Road to TeamSTEPPS…

17. The Components of a Patient Safety Program 17 17

18. Introduction Evolution of TeamSTEPPS Curriculum Contributors • Department of Defense • Agency for Healthcare Research and Quality • Research Organizations • Universities • Medical and Business Schools • Hospitals—Military and Civilian, Teaching and Community-Based • Healthcare Foundations • Private Companies • Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM) 18 18

19. Institute of Medicine Report“To Err is Human” (1999) Impact of Error: 44,000–98,000 annual deaths occur as a result of errors Medical errors are the leading cause, followed by surgical mistakes and complications More Americans die from medical errors than from breast cancer, AIDS, or car accidents 7% of hospital patients experience a serious medication error Cost associated with medical errors is $8–29 billion annually. 19 19

20. JCAHO Sentinel Events Targets for Teamwork 20 20

21. (Pronovost, 2003) Johns Hopkins Journal of Critical Care Medicine (Sexton, 2006) Johns Hopkins (Mann, 2006) Beth Israel Deaconess Medical Center Contemporary OB/GYN 21 21

22. TeamSTEPPS Key Principles • Team Structure • Leadership • Situation Monitoring • Mutual Support • Communication

23. Paradigm Shift to Team System Approach Dual focus (clinical and team skills) Team performance Informed decision-making Clear understanding of teamwork Managed workload Sharing information Mutual support Team improvement Team efficiency Single focus (clinical skills) Individual performance Under-informed decision-making Loose concept of teamwork Unbalanced workload Having information Self-advocacy Self-improvement Individual efficiency 23 23

24. High-Performing Teams Teams that perform well: Hold shared mental models Have clear, valued, and shared vision Have strong team leadership Engage in a regular discipline of feedback Develop a strong sense of collective trust and confidence Optimize resources Have clear roles and responsibilities Create mechanisms to cooperate and coordinate Manage and optimize performance outcomes (Salas et al. 2004) 24

25. Why Teamwork? “High-performance teams create a safety net for your healthcare organization as you promote a culture of safety." 25

26. Organize the team Articulate clear goals Make decisions through collective input of members Empower members to speak up and challenge, when appropriate Actively promote and facilitate good teamwork Skillful at conflict resolution Effective Team Leaders 26 26

27. A Continuous Process SituationMonitoring(Individual Skill) SituationAwareness(Individual Outcome) Shared Mental Model(Team Outcome) 27 27

28. Cross Monitoring 28 28

29. Shared Mental Model? 29 29

30. What Do You See? 30

31. Team members foster a climate in which it is expected that assistance will be actively sought and offered as a method for reducing the occurrence of error. “In support of patient safety, it’s expected!” Task Assistance 31 31

32. Characteristics of Effective Feedback Good Feedback is— TIMELY RESPECTFUL SPECIFIC DIRECTED toward improvement Helps prevent the same problem from occurring in the future CONSIDERATE FIRST HAND encouraged “Feedback is where the learning occurs.” 32 32

33. CHAIN EXERCISE 33 33

34. Using the materials in front of you, create a paper chain with the most links. You may only use your non-dominant hand AND you cannot speak. You have 2 minutes to create this chain.

35. ™ Strategies and Tools to Enhance Performance and Patient Safety TOOLS

36. Leadership Tools ™

37. Briefing Checklist

38. Debrief Checklist

39. MUTUAL SUPPORT Conflict Resolution Tools ™

40. Two-Challenge Rule Invoked when an initial assertion is ignored… • It is your responsibility to assertively voice yourconcern at least two times to ensure thatit has been heard • “Empower any member of the team to “stop the line” if he or she senses or discovers an essential safety breach.” • If the outcome is still not acceptable: • Take a stronger course of action • Use supervisor or chain of command

41. Please Use CUS Wordsbut only when appropriate!

42. Communication Tools Assumptions Fatigue Distractions HIPAA ™

43. R-SBAR • “I am concerned about………” • “I need you to come in now because….” • Situation―What is going on with the patient? • Background―What is the clinical background or context? • Assessment―What do I think the problem is? • Recommendation―What would I recommend? Remember to introduce yourself…

44. Check-Back is…

45. Team Effectiveness BARRIERS • Inconsistency in Team Membership • Lack of Time • Lack of Information Sharing • Hierarchy • Defensiveness • Conventional Thinking • Complacency • Varying Communication Styles • Conflict • Lack of Coordination and Follow-Up with Co-Workers • Distractions • Fatigue • Workload • Misinterpretation of Cues • Lack of Role Clarity TOOLS and STRATEGIES Brief Huddle Debrief STEP Cross Monitoring Feedback Advocacy and Assertion Two-Challenge Rule CUS Collaboration SBAR Call-Out Check-Back Handoff OUTCOMES • Shared Mental Model • Adaptability • Team Orientation • Mutual Trust • Team Performance • Patient Safety!!

46. Perinatal Safety Program ■ Mandatory Team STEPPS Training ■ Mandatory Simulation Training ■ Implementation of Laborist Program ■ Leadership Rounds ■ Quality Initiatives ● Intradepartmental Performance Improvement ● Peer Review ● Case Conferences ■ Mandatory Debriefing

47. Team STEPPS Team Assessment Questionnaire “The team is a safety net for patients.” Pre Team STEPPS training Post Team STEPPS training