How Safe Are Our Hospitals?

1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future How Safe Are Our Hospitals? Clinical Professor of Pediatrics President, Caritas Norwood Hospital Senior Vice President for Quality and Patient Safety Caritas Christi Healthcare System John B. Chessare, M.D., M.P.H. May 18, 2006 8:30-9:00am

2. QUESTION: How much do you think the safety at your institution can be enhanced? • Greatly enhanced • Moderately enhanced • Minimally enhanced • No enhancement needed 0/0

3. QUESTION: In your opinion, which of the following is the most important attribute of a high reliability organization? • Preoccupation with failure • Reluctance to simplify interpretations • Sensitivity to operations • Commitment to resilience • Deference to expertise 0/0

4. Objectives • Discuss the current state of hospital safety • Describe the steps to higher reliability and safer care

5. A question to run on …… “What can I do as a leader in healthcare to make our care safer and more effective?”

6. Agenda Introduction and the State of Patient Safety 8:30 - 8:35 A real error: Caritas Norwood Hospital, Dec 23, 2005 8:35 – 8:40 Reliability, Complex Systems, and System Failure 8:40 – 8:50 Getting in Action: Building a Culture of Safety and Continual Improvement 8:50 – 9:00

8. AHRQ 2005 National Healthcare Quality Report Summary • Health care quality continues to improve at a modest pace across most measures of quality. • Health care quality improvement is variable, with notable areas of high performance. • Health care quality is improving, but more remains to be done to achieve optimal quality. • Sustained rates of quality improvement are possible.

9. AHRQ 2005 National Healthcare Quality Report 4 Dimensions Considered: • Effectiveness • Patient Safety • Timeliness • Patient Centeredness

10. AHRQ 2005 National Healthcare Quality Report Summary • Patient Safety Dimension Indicators • Complications of Care: • Central line associated bloodstream infections in ICU patients • Ventilator Associated Pneumonia in the ICU • Medicare beneficiaries with post-op PE or DVT • Medicare beneficiaries with central venous catheter associated mechanical complication • Prescribing medications: • Elderly with inappropriate medications

11. AHRQ 2005 National Healthcare Quality Report Figure: Median rate of improvement, by health care dimension

12. We give a patient 10 times his usual insulin dose • A man with chronic medical problems came to the Emergency Department and was seen by the triage nurse. The nurse wrote the man’s list of medications on the medication reconciliation form. • The nurse wrote 100 U on the form, then scratched it out and wrote 6 U as the dose of insulin. After the fact, the nurse stated that he had heard of the dangerous abbreviation list. The nurse also stated that he didn’t know how what he had written could have been misinterpreted).

13. We give a patient 10 times his usual insulin dose • It was determined that the man needed to be admitted and a Hospitalist physician evaluated him in the Emergency Department. The physician reviewed the man’s outpatient meds on the reconciliation form and cosigned the form as this was then to serve as one of the patient’s admitting order sheets. • After the fact, the physician stated that she never used the dangerous abbreviations and that she had not said anything to the nurse who had used the abbreviation. She also asked how she would have known who the nurse was since he had not printed his name after the signature and his name was illegible.

14. We give a patient 10 times his usual insulin dose • The patient was moved up to the med/surg unit where he was assigned to a floor nurse. The order sheet was faxed to the pharmacy. • The pharmacist read the order as 6 units, verified the order, and sent a correctly labeled vial of insulin to the floor. The pharmacist did not call the ordering physician. After the fact, the Pharmacy Director stated that the pharmacy did not call the ordering physician because it had been hours since the physician co-signed the order and the physician was not still on duty

15. We give a patient 10 times his usual insulin dose • The nurse went to the bulk medication drawer and took an insulin vial from a non-labeled vial that had once been sent up for another patient • The nurse read the order as “60” rather than “6U” and drew up 60 units of regular insulin

17. We give a patient 10 times his usual insulin dose • The nurse then checked the dose in the syringe with another nurse. The second nurse did not check the order but was checking against what the first nurse said the dose was. • The nurse then gave the insulin to the patient. She told him what she was giving and as she was injecting the med the patient said “Ok, but I usually get 6 units”. The nurse then realized her error. • The nurse then called the physician and verified that the dose was to have been 6 units of regular insulin. The patient was given sugar and watched closely. The patient was informed of the error and did well.

18. What happened in this case? We are now less likely to give the people involved in the case a punishment, a lecture and then to move on.

19. “Hard work and good intentions are necessary but insufficient for exceptional care.”

20. We are now less likely to exhort people to be more vigilant and are more likely to understand that…….

21. “Every System is perfectly designed to get exactly the results that it gets.”

22. Reliability, Complex Systems, and System Failure • Reliability means: what should happen happens and what should not happen doesn’t. • “Medication orders are carried out correctly at our hospital 97% of the time”. • The medication system for children at this hospital is 97% reliable

23. Industry Nuclear Power Commercial Aviation Medical Care Reliability* High High Low High Risk Industries * What should happen, happens and what shouldn’t happen, doesn’t happen.

24. Different Views of Reliability

25. Health Care Process Reliabilities For further reading, see: McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine. 2003;348.

26. Design for Reliability Level 1. Intent, vigilance and hard work Level 2. Design informed by reliability science and research in human factors Level 3. Design of high reliability organizations (Weick) For further reading, see: McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New England Journal of Medicine. 2003;348.

27. René Amalberti Increasing safety margins No limit on discretion Becoming team player Excessive autonomy of actors Agreeing to become « equivalent actors » Craftmanship attitude Accepting the residual risk Ego-centered safety protections, vertical conflicts Accepting that changes can be destructive Loss of visibility of risk, freezing actions Blood transfusion Fatal Iatrogenic adverse events Anesthesiology ASA1 Cardiac Surgery Patient ASA 3-5 Medical risk (total) No system beyond this point Himalaya mountaineering Chartered Flight Civil Aviation Railways (France) Microlight or helicopters spreading activity Road Safety Chemical Industry (total) Nuclear Industry Fatal risk 10-2 10-3 10-4 10-5 10-6 Very unsafe Ultra safe

28. Attributes of a High Reliability Organization Sophisticated design of human interactions and working relationships • Preoccupation with failure • Reluctance to simplify interpretations • Sensitivity to operations • Commitment to resilience • Deference to expertise Weick

29. In Complex Systems • Catastrophes don’t have one “root” cause. • The latent errors are in the system all the time. They often don’t get addressed until there is a catastrophe. • The safest organizations don’t wait for the catastrophe to fix them.

30. ……so lets go back to our case ………

31. The nurse took the drug from a stash. We do whatever we need to do in the Moment vs. following the safety design. We know that people are still Using dangerous abbreviations And allow it to happen “Checking nurse Doesn’t check the Order or emar. Nurse involves patient too late in process. Nurse uses a dangerous abbreviation We know thatdrugs are being Kept on the floor outside of Protocol and do not stop this. We don’t confront each other for safety sake. The physician signed the order with dangerous abbreviation. The pharmacist filled the order with the dangerous abbreviation.

32. Getting in Action: Building a Culture of Safety and Continual Improvement • Declare it! • Use performance improvement as the business model • Create a guiding coalition • Require a basic educational competency • Create a medication safety team • Flowchart the existing medication delivery system • Redesign error prone steps; automate when possible

33. Getting in Action: Building a Culture of Safety and Continual Improvement 8. Reward reporting 9. Study the incidents 10. “Celebrate” errors; tell the story; make errors visible to all 11. Shorten the time to action 12. Measure and set goals 13. Review the medication safety system at regular intervals

34. 1. Declare it! • The leader must declare that low reliability performance is unacceptable. • This message should be communicated in as many ways as possible

35. 2. Use performance improvement as the business model - how we get to higher levels of reliability. • Focus on the patient and his or her family • Deep Process knowledge (Design) • Decisions driven by data • Teamwork • Empowerment Too Much is Happening by Chance! Too little by Design!

36. 3. Create a guiding coalition • Ideally, the hospital (or practice) president, the Chief of Staff, Pharmacy Director, and Vice President for Nursing oversee the system. • If you can’t get the person’s attention….DO IT YOURSELF!

37. 4. Require a basic educational competency For example: require all nurses, ordering physicians, and pharmacists to attend a session on complex systems and safety

38. 5. Create a medication safety team • Have team members be a mix of “managers” and line workers • Tasks: (see further steps) create or improve the reporting system; meet at regular intervals to learn from reports and test changes as soon as possible after a report (hours or days not weeks or months); review progress against goals

39. 6. Flowchart the existing medication delivery system • Get enough information on paper to identify areas for improvement. • Caution: don’t spend a lot of time defining perfectly what you are about to “blow up”.

40. 7. Redesign error prone steps; automate when possible • Do this in parallel with the Medication Safety Team error report review • “Good to Great”: use automation as an accelerator of change; not the main focus of change; the main focus should be in creating higher reliability • Caution: automation does not eliminate all error. It only moves the likely point of error to the man-machine interface.

41. 8. Reward Reporting • Have the Medication Safety Team invite reporters to their meetings. • Call and thank reporters. • Find reporters on the “units” when you make changes to the system. • Thank reporters at public meetings. • Give token gifts: coffee coupons etc.

42. 9. Study and learn from reported incidents • Design a reporting form or format that values the time of the reporter but gets the story from those involved • Ask the reporter for solutions to be tested (see the aviation safety reporting system at http://asrs.arc.nasa.gov/main.htm )

43. 9. Study and learn from reported incidents When you have a meeting to discuss an event or near miss: • Have a senior person run the meeting (President, VPMA) who is versed in analysis • State that the main reason for meeting is to prevent a catastrophe or another catastrophe • Allow all involved to tell their story before others join in with comments or questions • Clearly identify next steps and accountable parties for the changes

44. 10. “Celebrate” errors; tell the story; make errors visible to all • Email stories to all who might find themselves in a similar situation with the fix included if possible • President highlights events at meetings and in newsletters • Local managers repeat stories to staff and engage in dialogue

45. 11. Shorten the time to action • When you get a report of an event or near miss, act as if your loved one was about to undergo the same procedure this afternoon • “What could we change/test now to make the process safer?”

46. 12. Measure and set goals • “We will reduce the rate of reported medication errors that reach the patient to less than 1 per 1000 patient days”. • In addition to the voluntary reporting system use “trigger” reports. (See IHI.org)

47. 13. Review your medication, OR, etc. safety systems at regular intervals • In the spirit of continuous improvement, your safety system can always be made better. • Have the captain of the Medication Safety Team report annually to the Board of Trustees of the organization.

48. Summary • Humans will not stop making errors • Systems must be designed to protect against human errors • We are implementing the science of other high reliability industries • We are making our hospitals safer but at a slow rate • If we get in action we can go faster • Thanks very much

49. A question to run on …… “What can I do as a leader in healthcare to make our care safer and more effective?” “What will you do when you return to work?”

50. Please give feedback on this session! Thank You!