Risk Management & Patient Safety · Improve patient care through the strengthening of systems and...
Transcript of Risk Management & Patient Safety · Improve patient care through the strengthening of systems and...
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Risk Management & Patient Safety
Noelani Warren, PhD., RNDirector for Risk Management & Patient SafetyRiverside Service Area
Regional Advanced Perianesthesia Course
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FINANCIAL DISCLOSURE
Disclosure: The faculty and planners for this activity do not have any relevant financial relationships with
commercial interests or affiliations to disclose.
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3 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
Objectives
To utilize safety check and escalation protocol when applicable
To participate in comprehensive systematic analyses as needed
Questions
To identify potential risks and report them, including near misses
To utilize TeamSTEPPS principles in team communication
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WHY: Medical Errors 3rd most common cause of death
4 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
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What does Risk Management do?
Improve patient care through the strengthening of systems and processes
Facilitate investigations, identify causes, and potential solutions
Handle legal claims and board reports
Non-punitive, invisible consultants, not to be documented in the record
We represent you, your physicians, AND the patient
We uphold safety science
5 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
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6 | Copyright © 2017 Kaiser Foundation Health Plan, Inc.
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Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year
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Not errors but learning opportunities
“ALL MEN MAKE MISTAKES
BUT ONLY WISE MEN LEARN FROM THEIR MISTAKES”
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2011-2017 Legal Costs
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SCAL Significant Events 2014 - 2019
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Comprehensive Systematic Analysis: Cause Map
11 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
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UNFORTUNATELY TECHNOLOGIES AND POLICIES NEED TO
BE IMPLEMENTED BY PEOPLE.
TO ERR IS HUMAN…
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13 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
Strategies and Tools to Enhance Performance and Patient Safety
Great technologies, Policies and Procedures are not the only factors in Patient Safety, Human Factors
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Providing Excellent Care requires a Team effort
14 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
TeamSTEPPSExpert Team
Team of Experts
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First Step: SPEAK UP
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Encourage the reporting of suggestions, compliments, or problems
Supervisor
Chief of Service, Medical Director
Charge Nurse, Unit Manager
Safety Check, Please
Unusual Occurrence Report/Patient Safety
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Common Themes of CSAs
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Most arise from system problems and not individual behaviors
– The majority have NO malicious intent
– Bad things happen to good people
Policies are already in place but not alwaysfollowed
– The core issue in drift
Importance of Learning Opportunities and recognizing exemplary behavior (Good Catches)
– Constructive vs. Destructive
– Second victim- usually the biggest advocate
– It is HOW we react to errors that determines whether we LEARN from them.
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Swiss Cheese Model
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18 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
Strategies and Tools to Enhance Performance and Patient Safety
What is TeamSTEPPS
National Program developed by Department of Defense's Patient Safety Program in collaboration with the Department of Health and Human Services Agency for Healthcare Research and Quality
Scientifically rooted in more than 20 years of research and lessons from the application of teamwork and communication principles
A source for ready-to-use materials and a training curriculum to successfully integrate teamwork principles into all areas of your health care system
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First Agenda
TeamSTEPPS Framework
Leadership Delegation, Facilitate Team Events (Briefs, Huddles, Debriefs), Conflict Resolution
Communication SBAR, call-outs, cross-checks, check-backs
Situation Monitoring: Awareness & Shared Mental Model
Mutual Support: Task Assistance, Feedback, Assertion, Conflict Skills (2 Challenge Rule, CUS), Collaboration
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20 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
Strategies and Tools to Enhance Performance and Patient Safety
Great technologies, Policies and Procedures are not effective if not practiced 100% of the time
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21 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
40 yo female post right inguinal hernia repair, extensive Marcaine used at the surgical site due to patient’s low pain tolerance per history
General Anesthesia with LMA
Recovered well, upon discharge patient’s leg buckled
Documentation did not address if patient could bear weight or how she ambulated
Patient was kept for 30 more minutes and discharged
About 10 days later patient told PCP she fell in PACU after surgery
Case Study 1
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22 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
65 yo Spanish speaking male in pre-op for colon resection surgery
Patient consent was in English and there is no translator available
General anesthesia
During intraoperative phase patient experience marked bleeding and required blood transfusions
Upon report to PACU, 1 more unit of blood was due and brought over by Anesthesiologist
Blood was hung, within 7 minutes patient began experiencing rigors and blood pressure began to drop
EMR showed patient was O+ and blood hanging was A+
Case Study 2
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23 | © 2011 Kaiser Foundation Health Plan, Inc. For internal use only.August 22, 2019
36 yo male was in pre-op for left rotator cuff repair.
Anesthesiologist at bedside to prepare for block
During infusion of local anesthetic patient experienced seizure
Patient was given versed IV and taken to OR for surgery
After surgery family was informed of seizure in pre-op
Case Study 3
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The devil is in the details….DOCUMENT
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Nursing UOR-O (Unusual Occurrence Reports- Online)KP.ORG/UORO
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Questions???
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keep our patients safe