Lee Patient Safety Presentation for Pharmacy Talk. WORKING...
Transcript of Lee Patient Safety Presentation for Pharmacy Talk. WORKING...
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Understanding the Founda0ons of Pa0ent Safety & Applying the Principles of High Reliability
to the Healthcare Environment
Commun i c at i o n
Cu l t ure
Mindfulness Reliability
Laura M. Lee, MS, RN Director, Office of Pa6ent Safety and Clinical Quality
Na6onal Ins6tutes of Health Clinical Center
Disclosures
• I have no financial interest to disclose.
• This con6nuing educa6on ac6vity is managed and accredited by the Professional Educa6on Services Group in coopera6on with the NIH Pharmacy Department. PESG, NIH, and all accredi6ng organiza6ons do not support or endorse any product or services men6oned in this ac6vity.
• PESG and NIH staff have no financial interest to disclose.
Learning Objec6ves
• Describe the magnitude and impact of errors and harm in healthcare; specifically in the medica6on management domain
• Discuss how the principles of High Reliability Organiza6ons can be applied to the healthcare and pharmacy environments
• Relate how an organiza6on’s culture impacts pa6ent safety and describe strategies to improve an organiza6on’s safety culture
At the conclusion of this ac/vity, the par/cipant will be able to:
Obtaining CME/CE Credit
If you would like to receive con6nuing educa6on credit for this ac6vity, please visit:
hSp://nih.cds.pesgce.com
How Safe Is Health Care? Bungee Jumping – REALLY????
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Clinical Research: Heightened Responsibility
Pa0ent Care
Clinical Researc
h COMPLEXITY
RISK
Healthcare Complexity • Diversity of tasks involved in the delivery of pa6ent care; • Dependency of health-‐care providers on one another; • Diversity of pa6ents, clinicians and other staff; • Rela6onships between pa6ents, health-‐care providers, support staff, administrators, family, and community members;
• Vulnerability of pa6ents; • Impact of technology; • Clinical research mission
Ac#ve error: An error that occurs at the level of the frontline operator and whose effects are felt almost immediately
Latent error: Organiza6onal or design decisions made away from the bedside that impact the care and contribute to the occurrence of errors or allows them to cause harm to pa6ents.
Sharp end: The “actualizer” of the process—the person actually doing the task (e.g., the nurse administering a medica6on; the surgeon holding the scalpel)
Blunt end: Parts of the process farther away from the ac6on itself; the environment in which we deliver healthcare.
Preventable event: An event that could have been an6cipated and prepared for, but that occurs because of an error or other system failure
The Language of Harm
Levels of defense
Medication
Allergy
Reason’s Swiss Cheese Model
Factors that Influence Safety Systems
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• An interdependent group of items forming a unified whole
System
• A system in which there are so many interac6ng parts that it is difficult, if not impossible, to predict the behavior of the system based on knowledge of its component parts
Complex System
Think: Systems!
Person Approach – Focus on individual – Errors are a product of carelessness
– Interven6ons: • Naming • Blaming • Shaming
• Retraining
– Target is the individual
System Approach
– Focus on condi6ons and environment
– Interven6ons: • Improving the system
– Targets • Pa6ent and provider factors • Task Factors • Technology and tool factors • Team factors • Environmental factors • Organiza6onal factors
Person vs. System
Culpable Blameless
Malicious Act
Fitness for Duty Issue System
Failure
Reckless Behavior
NO
YES YES YES NO
YES
NO
YES NO
YES
System Failure
At-‐risk Behavior
YES
System Failure
NO
Managing Unsafe Events in the Clinical Center: A Strategic Model
NO NO Did the employee act inten6onally?
Does there appear to be evidence of
impairment (e.g., ill health, substance
abuse)?
Did the employee knowingly violate safe procedures?
Would another individual from the same professional group with comparable
qualifica6ons and experience, behave in the same way?
Were the consequences as
intended?
Were the procedures easy to understand and follow?
Were there deficiencies in
training, experience, and supervision? Human Factors
Human factors refer to environmental, organizational and job factors, and human and
individual characteristics which influence behavior at work in a way which can affect
health and safety. Health and
safety-related behavior
Job
Individual
Organization INFLUENCE
Human Factors & Pa6ent Safety Human Factors
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Human Factors & Pa6ent Safety
• The complexity of health care is fraught with human factors issues
• Major contributor to medical error
Processes Products
• Individual Characteris6cs – Knowledge, skill level, experience, intelligence,
aitude, fa6gue, stress, mo6va6on
• Nature of the Work – Design of the work processes, pa6ent loads, presence/absence of
teamwork, complexity of treatments, equipment used, interrup6ons and compe6ng tasks,
• Human-‐System Interfaces
– Pa6ent-‐Device interface, Prac66oner-‐Device interface, Micro-‐system-‐Device interface, Socio-‐technical-‐Device interface, equipment loca6on, sojware control, electronic health record (CRIS)
Human Factors
• The Physical Environment – Architecture, interior design and layout,
availability and placement of equipment, work flow in space, ligh6ng, noise, temperature, distrac6ons
• Organiza6onal/Social Environment – Authority/power gradients, group norms and culture ,
communica6on/coordina6on, “local” procedures/prac6ce, work life quality, normaliza6on of deviance
• Management – Organiza6onal structure, leadership, staffing/pa6ent load, resource
availability, culture, accountability of prac66oners, employee development
• External Environment – Clinical research environment, poli6cal pressures, economic pressures,
public awareness, new technology, media
Human Factors • Gradual process in which an unacceptable prac6ce or standard
becomes acceptable
• Organiza6on/staff become so insensi6ve to deviant prac6ce that it no longer feels wrong
• As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the person/team/organiza6on
Normaliza6on of Deviance
1. Staff believe that rules are not well conceived and inefficient – developed by those who are not in the trenches of care.
2. Staff lack of knowledge – knowledge is imperfect and uneven and some staff may not even know the reasons for the prac6ce and procedure.
3. New technologies – can disrupt ingrained prac6ce paSerns, impose new learning demands, or force system operators to devise novel responses or accommoda6ons to new work challenges.
4. Staff belief that it is OK to break a rule for the good of the pa6ent.
5. Staff belief that rules don’t apply to them – they have experience and can be trusted.
6. Staff fear about speaking up when deviant behavior is observed.
7. Leadership awareness of deviant behavior or systems problems but there is a failure to bring it up the chain of command.
Normaliza6on of Deviance
Communica6on
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0 20 40 60 80
Continuum of CareMedication Use
Care PlanningOperative Care
Information ManagementPhysical Environment
Human FactorsAssessmentLeadership
Communication
Ineffective communication
is a root cause in approximately
66% of Sentinel Events
Data Indicate….
• Communica6on is the “the process by which informa#on is clearly and accurately exchanged between two or more team members in a prescribed manner and with proper terminology and the ability to clarify or acknowledge the receipt of informa#on” (AHRQ, n.d.)
Communication
Individual Level Barriers • Language • Lack of trust • Cultural differences • Gender difference • Mul6ple/split loyal6es • Lack of team experience • Distrac6ons
Team or Microsystem Level Barriers • Lack of well-articulated goals or purposes • Role and leadership ambiguity • Lack of structure or framework for
problem-solving • Workload • Power and authority • Traditional hierarchical differentials • Lack of leadership and vision • Personal conflicts among team members • Diffusion of responsibility • Interprofessional rivalries • Lack of effective information sharing
processes
Organizational Level Barriers • Lack of leadership and vision • Resource availability • Legal constraints • Rigid decision-making processes
Communication Barriers
The balance of decision-making power or the steepness of command hierarchy in a given situation
Authority/Power Gradients
Experienced/Leader
Inexperienced/Subordinate
STEEP
FLAT Peer Peer
Authority/Power Gradients
• Most teams require some degree of authority gradient
• Otherwise roles are blurred and decisions cannot be made in a timely fashion.
• Healthcare environment is a very hierarchical world with inherent power distances
Authority/Power Gradients
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It could happen here -‐ -‐ -‐ -‐ • Pharmacist calling a physician to clarify an incorrect inves6ga6onal new drug order is met with anger and impa6ence and this comment: “And when did you get your medical degree??”
• Fellow afraid to ques6on an aSending’s an6coagula6on order despite her certainty that the order was wrong
• Opera6ng room staff directed by senior surgeon to flash sterilize unconven6onal item for human use
Authority/Power Gradients
Express Concern
State Problem
Propose Ac6on
Reach Decision
Get Person’s ASen6on
Cycle of Assertion
“Stop the line”
What is your “Safety Language”
HIGH RELIABILITY
High Reliability Organiza6ons
• An error or lapse in safety in these industries’ processes can result in tragic outcomes
• Commercial airlines, aerospace, and nuclear power energy are among the most risky industries but are, in reality, the safest enterprises
• We approach the task of keeping our pa6ents, staff, and organiza6onal mission safe much like managing an airline or a nuclear power plant – we apply the five principles of high reliability
• Likewise, a lapse in proper infec6on control in the care of a pa6ent with Ebola virus infec6on or an error in the prepara6on or administra6on of a high risk medica6on can be catastrophic from a personal as well as an organiza6onal perspec6ve
Preoccupa6on with Failure
• We all need to be the “Eeyores” of the healthcare
• Always asking about, and looking for, untoward outcomes that could result from our care processes
• We ask “WHY?, WHY?, WHY?, WHY?, WHY? when things go wrong or nearly wrong (e.g., near miss)
• Tools from high reliability industries help us iden6fy risky processes and behaviors before we have a catastrophic event (e.g. Failure Mode and Effects Analysis)
• Drilling and conduc6ng “Day in the Life” drills/exercises is borne of this Preoccupa0on with Failure
Channeling Your Inner Eeyore
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Deference to Exper6se
• The old adage “Father knows best” does not rule the day
• Staff involved in the management of high risk procedures and the care of complex high risk pa6ent pa6ents (and all pa6ents, for that maSer) are the experts about how the processes we design will perform -‐ -‐ or more importantly, won’t perform – and, therefore, play the lead role in designing processes of care
• A challenge is managing the well-‐inten6oned “direc6ves” of staff and leadership who are removed from day to day bench-‐side or bed-‐side care but have a vested interest in the care of pa6ents
The C-‐Suite Plays Second Fiddle
Built-‐In Resiliency
• Every organiza6on must develop strategies to sustain opera6ons and “bounce back” when (not if) an untoward event occurs
I Get Knocked Down and Get Back Up Again
• The ques6on “What if?” needs to end every process step designed in the care of high risk pa6ents
o What if a pharmacists dispenses the wrong drug or if a staff person experiences an occupa6onal exposure?
o What if the public has a nega6ve reac6on to a sen6nel event involving a medica6on or there is a breach in technique?
Sensi6vity to Opera6ons
• Leaders and staff need to be constantly aware of how processes and systems affect the organiza6on
• “Safety huddles” should be used liberally. In safety huddles staff gather briefly (five –ten minutes) to discuss issues/concerns that have developed over the course of their tour of duty
• Each employee pays close aSen6on to opera6ons and maintains awareness as to what is, or isn't, working
• Leadership huddles are equally important to review what is working or not working each day
Eyes in the Back of My Head
Reluctance to Simplify Processes
• Resist simplifica6ons! Look beyond the obvious!
• The me6culous aSen6on to detail in the complex opera6ons of a pharmacy and medica6on management is an example
• May be beneficial to simplify some work processes but avoid failing to dig deeply enough to understand an issue
The Devil is in the Details
• The ques6on: “What if?” needs to end every process step designed in the care of high risk processes and pa6ents
Pa6ent Safety Culture
An organiza6on’s values and behaviors —modeled by its leaders and
internalized by its members — that serve to make pa6ent safety the
overriding priority.
Pa6ent Safety Culture • Acknowledgment of the high-‐risk nature of our work;
• A dogged determina6on to achieve safety;
• A blame-‐free environment where individuals are able to report errors or near misses without fear of reprimand or punishment;
• A commitment to learn from errors;
• Encouragement and expecta6on of collabora6on across departments and disciplines to solve pa6ent safety problems;
• Leadership commitment to, and involvement in, pa6ent safety.
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Doing it RIGHT!
“Error is the starting point;
not the conclusion” Sydney Dekker - “The Field Guide to Understanding Human Error”