First Do No Harm First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician...

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First Do No Harm First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician Education Part 2: Safety Behaviors for Error Prevention

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Transcript of First Do No Harm First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician...

Page 1: First Do No Harm First, Do No Harm: Building a Culture of Patient Safety at Novant Health Physician Education Part 2: Safety Behaviors for Error Prevention.

FirstDo No Harm

First, Do No Harm:

Building a Culture of Patient Safety at Novant Health

Physician EducationPart 2: Safety Behaviors for Error Prevention

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Objective: 1. Provide an in-depth review of the five

organization-wide Safety Behaviors here at Novant Health

Goal and Objective

Goal: Understand the Novant Safety Behaviors and commit to making them personal work habits

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Our Novant Safety Behaviors &Error Prevention Tools

1. Practice with a Questioning AttitudeA. Stop, Reflect & Resolve in the face of uncertainty

2. Communicate ClearlyA. Use SBAR-Q to share informationB. Communicate using three-way repeat backs and read backsC. Use phonetic and numeric clarifications

3. Know & Comply with Red RulesA. Practice 100% compliance with Red Rules B. Expect Red Rule compliance from all team members C. If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved

4. Self-check: Focus on TaskA. Use the STAR technique   

5. Support Each OtherA. Cross-check and AssistB. Use 5:1 Feedback to encourage safe behaviorC. Speak up using ARCC – “I have a concern”

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What should we do?Think critically by questioning information we hear and

see if it doesn’t fit with what we know

Why should we do this?– To detect incorrect information and assumptions that can

lead to erroneous decisions or actions– To help ensure work activities are stopped when faced with

uncertainty or unsafe conditions

Error Prevention Tool– Stop, Reflect and Resolve

1. Practice with a Questioning Attitude

Its not about asking questions – its about

questioning the answers!

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Stop, Reflect and Resolve

Stop: Review the plan – do not proceed in the face of uncertainty

Reflect: Does it make sense to me?

Resolve: Check it out with an independent, expert source

Patient

Technology

Professionals

Medical RecordDocumentation Procedures

& References

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• Does this make sense to me? Is it right, based on what I know?

• Is this what I expected?• Does this information “fit-in” with my past experience

or other information I may have at this time?

Get in the habit of asking these questions all the time…

it takes only seconds.

Our internal smoke detector…

ExpectationCurrentSituation

Reflect - An internal check

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Resolve - An external check

When should you resolve?

• When your detector goes off

• In every high-risk situation

• When there is a change in the patient condition or plan of care

It’s okay not to know…It’s NOT okay not to find out.

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Our Novant Safety Behaviors – Communicate Clearly

1. Practice with a Questioning AttitudeA. Stop, Reflect & Resolve in the face of uncertainty

2. Communicate ClearlyA. Use SBAR-Q to share informationB. Communicate using three-way repeat backs and read backsC. Use phonetic and numeric clarifications

3. Know & Comply with Red RulesA. Practice 100% compliance with Red Rules B. Expect Red Rule compliance from all team members C. If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved

4. Self-check: Focus on TaskA. Use the STAR technique   

5. Support Each OtherA. Cross-check and AssistB. Use 5:1 Feedback to encourage safe behaviorC. Speak up using ARCC – “I have a concern”

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What should we do?

Ensure that we hear things correctly and understand things accurately

Why should we do this?– To prevent wrong assumptions and misunderstandings

that could cause us to make wrong decisions

Error Prevention Tools– SBAR-Q to Transfer Information

– 3-Way Repeat Backs and Read Backs

– Ask and Encourage Clarifying Questions

– Phonetic & Numeric Clarifications

2. Communicate Clearly

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SBAR-Q

An outline for planning and communicating information

about a patient condition or any other issue or problem

Situation: What is happening right now?

Background: What are the circumstances leading up to this situation?

Assessment: What do I think the problem is?

Recommendation: What should we do to correct the problem?

Questions: Follow up questions?

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SBAR-Q: Questions

Top 3 Statements to Encourage Critical Thinking1

1. “What do you think?”2. “That is an interesting question”3. “Let’s explore this”

Asking a question is primarily an emotional security issue. We can foster a culture of critical thinking by encouraging questions. Invite questions, and use positive reinforcement when questions are asked.

Encourage questions by inviting questions and positively reinforcing

questions when asked

A great way to help break down perceived

Power Distance!1Rubenfeld, “Critical Thinking Tactics for Nurses”

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Repeat Back / Read Back

1

2

3

Sender initiates communication using Receiver’s Name. Sender provides an order, request or information to Receiver in a clear and concise format.

Receiver acknowledges receipt by a repeat-back of the order, request or information.

Sender acknowledges the accuracy of the repeat-back by saying, That’s correct! If not correct, Sender repeats the communication.

Invite yourself in:“Let me repeat that back…”

Train our ears to listen for “That’s Correct!” – it’s a codeword

for “we understand each other”

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Clarifying Questions

Use the Safety Phrase:“Let me ask a clarifying

question…”

Asking clarifying questions can reduce the risk of making an error by 2½ times!

Why… How…

Ask one to two clarifying questions:– In all high risk situations– When information is

incomplete– When information is not clear

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Numeric Clarifications

For sound alike numbers,

say the number and then the digits…

15…that’s one-five

50…that’s five-zero

45…that’s four-five

425…that’s four-two-five

4 to 5…that’s the range four dash five…and ALWAYS use leading zeros – as in 0.9

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Phonetic Clarifications

A Alpha

B Bravo

C Charlie

D Delta

E Echo

F Foxtrot

G Golf

H Hotel

I IndiaJ JulietK KiloL LimaM MikeN NovemberO OscarP PapaQ Quebec

R RomeoS SierraT TangoU UniformV VictorW WhiskeyX X-rayY YankeeZ Zulu

For sound alike words and letters, say the letterfollowed by a word that begins with the letter…

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A Repeat Back Failure

27

527

“The Same”

29

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Our Novant Safety Behaviors – Know & Comply with Red Rules

1. Practice with a Questioning AttitudeA. Stop, Reflect & Resolve in the face of uncertainty

2. Communicate ClearlyA. Use SBAR-Q to share informationB. Communicate using three-way repeat backs and read backsC. Use phonetic and numeric clarifications

3. Know & Comply with Red RulesA. Practice 100% compliance with Red Rules B. Expect Red Rule compliance from all team members C. If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved

4. Self-check: Focus on TaskA. Use the STAR technique   

5. Support Each OtherA. Cross-check and AssistB. Use 5:1 Feedback to encourage safe behaviorC. Speak up using ARCC – “I have a concern”

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What Is A Red Rule?An act having the highest level of risk or consequence to patient or employee safety if not performed exactly, each and every time

“Red” designates the rule as a safety absolute with the highest

priority for exact compliance

3. Know and Comply with Red Rules

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Red Rules…For Times WhenThere Are No Do-Overs

Comair Flight 5191 crashed in Lexington, KY on Sunday August 27, 2006. Of the 47 passengers and 3 crew, 49 people died.

The plane cleared for take off on Runway 22 but taxied on the shorter Runway 26 instead. Not having enough distance to take off, the plane crashes after hitting a berm at the end of the runway.

Among the facts revealed by a January NTSB release was the violation of the "sterile cockpit" rule by the pilots, who talked about their families, pets, and jobs during taxi and takeoff.

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Novant Red Rules

1. I will always verify patient identity using 2 identifiers prior to any treatment, therapy, transport, procedure or specimen draw.

2. I will always perform “double checks” as specified by my department*.

*Note: Refer to your department “Double-Check” poster for

your safety-critical double-checks

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Our Novant Safety Behaviors – Self Check: Focus on Task

1. Practice with a Questioning AttitudeA. Stop, Reflect & Resolve in the face of uncertainty

2. Communicate ClearlyA. Use SBAR-Q to share informationB. Communicate using three-way repeat backs and read backsC. Use phonetic and numeric clarifications

3. Know & Comply with Red RulesA. Practice 100% compliance with Red Rules B. Expect Red Rule compliance from all team members C. If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved

4. Self-check: Focus on TaskA. Use the STAR technique   

5. Support Each OtherA. Cross-check and AssistB. Use 5:1 Feedback to encourage safe behaviorC. Speak up using ARCC – “I have a concern”

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What should we do?

Focus on the task at hand to avoid unintentional skill-based errors

Why should we do this?– To avoid those slips or lapses where the hand is operating

before the head– To reduce the chance that we’ll make an error when we’re

under time pressure, distracted or stressed

Error Prevention Tool

– Self Check Using STAR

4. Self Check – Focus on Task

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Self-Check Using STAR

Stop Pause for 1 to 2 seconds to focus your

attention on the task at hand

Think Consider the action you’re about to take

Act Concentrate and carry out the task

Review Check to make sure that the task was done

right and that you got the right result

STOP is the most important step. It gives your brain a chance to catch up with what your hands

are getting ready to do.

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Our Novant Safety Behaviors – Support Each Other

1. Practice with a Questioning AttitudeA. Stop, Reflect & Resolve in the face of uncertainty

2. Communicate ClearlyA. Use SBAR-Q to share informationB. Communicate using three-way repeat backs and read backsC. Use phonetic and numeric clarifications

3. Know & Comply with Red RulesA. Practice 100% compliance with Red Rules B. Expect Red Rule compliance from all team members C. If compliance with a Red Rule is not possible, STOP action until any uncertainty can be resolved

4. Self-check: Focus on TaskA. Use the STAR technique   

5. Support Each OtherA. Cross-check and AssistB. Use 5:1 Feedback to encourage safe behaviorC. Speak up using ARCC – “I have a concern”

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5. Support Each Other

What should we do?Look out for one other to catch each other’s mistakes while building a

greater sense of accountability for our actions

Why should we do this?– To help everyone perform at their individual best

– To help our team perform at it’s best

Error Prevention Tools– Cross Check and Assist

– Encourage Safe Behavior Using 5:1

– Speak Up for Safety Using ARCC – “I have a Concern”

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Cross-Checking in Healthcare

On your own, a person is only as reliable as a human can be:

1 defect per thousand opportunities

Cross-checking multiplies the error probability:

0.001 x 0.001 = 1 defect per million opportunities

High Reliability Organization (HRO) Lesson: Together we are

Six Sigma quality (3.4 dpmo*)Malcolm Baldrige National Quality Award

* defects per million opportunities

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Encourage Safe Behavior Using 5:1

Encourage and praise otherswhen they use safe and productive behaviors

Constructively correct and give advice to others

when they use unsafe and unproductive behaviors

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Speak Up for Safety Using ARCC

A Safety Phrase – “I have a Concern…”

Something I do to help our team prevent a safety event

Ask a question

Make a Request

Voice a Concern

Use the lightest touch possible…

If no success…Use Chain of Command

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A Speak up for Safety Failure• DC-8 from Denver to Portland with 189 people• While preparing to land, indications of unsafe landing gear extension

• National Transportation Safety Board (NTSB) findings– Captain failed to properly monitor fuel state– Captain failed to respond to crewmember’s advisories

regarding fuel state– Crewmembers failed to successfully communicate fuel concern

to Captain

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Speak Up for Safety Using ARCC

A Safety Phrase – “I have a Concern…”

Something I do to help our team prevent a safety event

Ask a question

Make a Request

Voice a Concern

Use the lightest touch possible…

If no success…Use Chain of Command

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20%

Even

t R

ate

Awareness

Skill Acquisition

Habit Formation

Performance

Time

100%

80% DecreaseIn Event Rate

Over 1-2 Years

2 Years

Current event rate, set at 100%

Our Goal – 80% Decrease in Serious Safety Events

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Novant Contact Information

• Sue DeCamp-Freeze• Senior Director Clinical Improvement• (704) 210-5767• [email protected]

• Catherine Fenyves• Patient Safety Manager• (704) 384-9329• Email: [email protected]


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