Compiled byKaye Culberson Wilkie, RN, BSN

Autopsy to Determine if Heparin Overdose Killed Texas Newborn

Multiple cancer patients killed by improperly programmed chemotherapy pump

To Err is HumanTo Err Is Human: Building a Safer Health System (1999 IOM report)98,000 die each year from medical errorMedical error kills more Americans than breast cancer, MVA, or

AIDS7% hospital patients experience serious medication errorCost = $8-29 billion/year Institute of Medicine (IOM) spearheaded initiative to improve

quality care IOM – skilled and caring professionals can – and do – make mistakes National agenda to reduce errors through design of safer delivery

systems

Impact of the Institute of Medicine’s (IOM) ReportCaptured media, public, political and professional

attentionShocking statisticsErrors caused by faulty systems/process focusCongressional hearings, President’s Task ForceImplementation of IOM’s recommendations…

IOM Recommendations

National focus to enhance knowledge base about safety

Identifying/learning from errorsRaising standards for improvements in safety

(oversight/benchmarking)Creating safety systems by implementing safe

practices (safety science) at the delivery level

Factors in Healthcare ErrorsWorkloadInterruptionsFatigueMulti-taskingFailure to follow upPoor handoffsIneffective

communicationTask fixation

Excessive professional courtesy

Halo effectHidden agendaComplacencyHigh-risk Not following

policy/procedure

Goal for quality and safety education for nurses is to prepare future nurses with:

KnowledgeSkillsAttitudes

Six competencies:Patient centered careTeamwork and collaborationEvidence-based practiceInformaticsQuality improvement Safety

Example: Patient-centered careKnowledge Skills Attitudes

Examine common barriers to active involvement of patients in their own health care process

Describe strategies to empower patients or families in all aspects of the health care process

Remove barriers to presence of families and other designated surrogates based on patient preferences

Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management

Respect patient preferences for degree of active engagement in care process

Respect patient’s right to access to personal health records

IOM Recommendations

National focus to enhance knowledge base about safety

Identifying/learning from errorsRaising standards for improvements in safety

(oversight/benchmarking)Creating safety systems by implementing safe

practices (safety science) at the delivery level

Quality Measure for Patient Centered Care

State variation: Adult ambulatory patients who reported good communication with health providers, 2007

Example: Teamwork and Collaboration

Knowledge Skills AttitudesDescribe own strengths, limitations, and values in functioning as a member of a team

Analyze own strengths, limitations, and values as a member of a team

Analyze impact of own advanced practice role and its contributions to team functioning

Clarify roles and accountabilities under conditions of potential overlap in team-member functioning

Guide the team in managing areas of overlap in team member functioning

Initiate and sustain effective health care teams

Acknowledge own potential to contribute to effective team functioning

Acknowledge own contributions to effective or ineffective team functioning

Appreciate the importance of inter-professional collaboration

PDSAPLAN: Plan a change or test of how

something works. DO: Carry out the plan. STUDY: Look at the results. What did you

find out? ACT: Decide what actions should be taken to

improve. Repeat as needed until the desired goal is achieved

Failure Mode Effects Analysis (FMEA)Failure modes are any errors or defects in a

process, design, or item, especially those that affect the patient, and can be potential or actual.

Effects analysis refers to studying the consequences of those failures.

Example: Evidence-based PracticeKnowledge Skills Attitudes

Explain the role of evidence in determining best clinical practice

Analyze how the strength of available evidence influences the provision of care (assessment, dx, tx, and evaluation)

Determine evidence gaps within the practice specialty

Read original research and evidence reports related to area of practice

Critically appraise original research and evidence summaries related to area of practice

Exhibit contemporary knowledge of best evidence related to practice specialty

Appreciate the importance of regularly reading relevant professional journals

Value knowing the evidence base for practice area

Value public policies that support evidence-based practice

Recognize importance of search skills in locating best evidence

Evidence-based Practice: what we know…

Evidence-based Practice: so…

Quality Measure for Evidence Based Practice

Adult surgery patients with postoperative catheter-associated urinary tract infection, overall and by selected comorbid conditions, 2006

Example: Quality ImprovementKnowledge Skills Attitudes

Describe strategies for learning about the outcomes of care in the setting in which one is engaged in practice

Describe strategies for improving outcomes of care in the setting in which one is engaged in practice

Explain common causes of variation in outcomes of care in the practice specialty

Seek information about outcomes of care for populations served in care setting

Use a variety of sources of information to review outcomes of care and identify potential areas for improvement

Assert leadership in shaping the dialogue and providing leadership for the introduction of best practices

Appreciate how unwanted variation affects care

Appreciate the importance of data that allows one to estimate the quality of local care

Appreciate that all improvement is change but not all change is improvement

Sentinel EventUnexpected occurrence involving death or serious

physical or psychological injury, or the risk thereof Serious injury specifically includes loss of limb or

functionThe phrase “or the risk thereof” includes any

process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

Sentinel Events

Root Cause Analysis (RCA)Aiming performance improvement measures at root

causes is more effective than merely treating the symptoms of a problem.

To be effective, RCA must be performed systematically, with conclusions and causes backed up by documented evidence.

There is usually more than one potential root cause for any given problem.

To be effective the analysis must establish all known causal relationships between the root cause(s) and the defined problem.

Root cause analysis transforms an old culture that reacts to problems to a new culture that solves problems before they escalate, creating a variability reduction and risk avoidance mindset.

Root Cause AnalysisDefine the problem. Gather data/evidence. Ask why and identify the causal relationships

associated with the defined problem. Identify which causes if removed or changed will

prevent recurrence. Identify effective solutions that prevent recurrence,

are within your control, meet your goals and objectives and do not cause other problems.

Implement the recommendations. Observe the recommended solutions to ensure

effectiveness. Variability Reduction methodology for problem solving

and problem avoidance.

Example: SafetyKnowledge Skills Attitudes

Discuss effective strategies for reducing reliance on memory

Describe processes used in understanding causes of error and allocation of responsibility (such as, root cause analysis)

Use appropriate strategies for reducing reliance on memory (such as, forcing functions and checklists)

Use organizational error reporting systems for near miss and error reporting

Engage in root cause analysis rather than blaming when errors or near misses occur

Appreciate the cognitive and physical limits of human performance

Value own role in preventing errors

Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team

Quality Measure for Safety

Hospital patients with adverse drug events, 2004-2006

Hospital Survey on Patient Safety Culture12 dimensions

1. Communication openness 2. Feedback & communication about error 3. Frequency of event reporting 4. Handoffs & transitions 5. Management support for patient safety 6. Nonpunitive response to error 7. Organizational learning--continuous improvement 8. Overall perceptions of patient safety 9. Staffing 10. Supv/mgr expectations & actions promoting patient safety 11. Teamwork across units12. Teamwork within units

Hospital Strengths & Areas for Improvement

1. Teamwork Within Units

2. Supervisor/Mgr Support for Patient Safety

3. Management Support for Patient Safety

4. Org Learning--Continuous Improvement

9. Teamwork Across Units

10. Staffing

11. Handoffs & Transitions

12. Nonpunitive Response to Error 44%

45%

55%

57%

70%

70%

75%

79%

Is it QI or is it PI?Quality improvement (QI) and performance

improvement are interchangeable termsQI/PI describe approaches to study and

improvement of processes…rememberPrimary focus should be on systems/process

rather than individual performance