Safety:Safety:It’s Everybody’s It’s Everybody’s

BusinessBusinessVirginia Ingram, MSN, RN Virginia Ingram, MSN, RN

vingram@hr.umsmed.eduvingram@hr.umsmed.edu

Patient Safety Officer Patient Safety Officer

University of Mississippi Medical University of Mississippi Medical CenterCenter

                                                                                                        

             

Too fast….too far down the runway!

““Most errors are made by Most errors are made by good but good but

fallible people, working fallible people, working in a in a

challenged and imperfect challenged and imperfect system.”system.”

Error is Inevitable Because Error is Inevitable Because of Human Limitationsof Human Limitations

* Limited memory capacity – 5-7 pieces Limited memory capacity – 5-7 pieces of information in short term memoryof information in short term memory

* Negative effects of stress – ↑ error Negative effects of stress – ↑ error rates rates

* Negative influence of fatigue and Negative influence of fatigue and other physiological factorsother physiological factors

* Limited ability to multitask – cell Limited ability to multitask – cell phones and drivingphones and driving

Human Error is Also Human Error is Also Inevitable Because:Inevitable Because:

* Safety is often assumed, not Safety is often assumed, not assuredassured

* Culture of the expert individual Culture of the expert individual – mistakes not allowed – mistakes not allowed

* AND…….AND…….

Complex, unsafe systemsComplex, unsafe systems

THEN WE HAVE HUMAN JUDGMENT

Oops! I forgot to set the Oops! I forgot to set the Brake!Brake!

Copyright © 1997-2005 Copyright © 1997-2005 AirDisaster.ComAirDisaster.Com. All Rights Reserved. . All Rights Reserved.

What can we learn from What can we learn from the Airline Industry? the Airline Industry?

Before intervention, Before intervention, 70% 70% of air crashes involved of air crashes involved

human error rather than human error rather than failures of equipment or failures of equipment or

weatherweather

Crew Resource Crew Resource ManagementManagement

* Focus on teamwork, communication, Focus on teamwork, communication, flattening hierarchy, managing flattening hierarchy, managing error, situational awareness, error, situational awareness, decision makingdecision making

* Non-punitive reporting of near Non-punitive reporting of near missesmisses

* Very open culture with regard to Very open culture with regard to error and safetyerror and safety

PATIENT SAFETYPATIENT SAFETY

Without Without Safety, there Safety, there is no Quality.is no Quality.

What is Patient Safety?What is Patient Safety?

In its simplest In its simplest form,form,

patient safety is patient safety is prevention of prevention of

harm to patients.harm to patients.

We are all in the We are all in the business of business of

Patient Safety!!!!Patient Safety!!!!

The Legal Fallacy of the The Legal Fallacy of the Low Risk PatientLow Risk Patient

There are NO LOW RISK There are NO LOW RISK patients! Most medical patients! Most medical legal claims come from legal claims come from low risk patients with low risk patients with poor outcomes !poor outcomes !

IT STARTED WITH THE IOM REPORT

NOVEMBER 1999 KEY FINDINGS:

PREVENTABLE MEDICAL ERRORS CAUSE 44,000-98,000 DEATHS/YEAR IN U.S.

ERRORS OCCUR BECAUSE OF SYSTEM FAILURES

PREVENTING ERRORS MEANS DESIGNING SAFER SYSTEMS OF CARE

JCAHO Patient Safety JCAHO Patient Safety GoalsGoals

Patient IdentificationPatient Identification Communication among caregiversCommunication among caregivers Medication SafetyMedication Safety Infusion PumpsInfusion Pumps Healthcare Acquired Infection Prevention Healthcare Acquired Infection Prevention Medication ReconciliationMedication Reconciliation Falls PreventionFalls Prevention Universal ProtocolUniversal Protocol Labeling of MedicationsLabeling of Medications Clinical AlarmsClinical Alarms

Sentinel EventsSentinel Events

SuicideSuicide of any individual receiving care or within 72 hours of of any individual receiving care or within 72 hours of dischargedischarge

Abduction Abduction of any individual receiving care, treatment or of any individual receiving care, treatment or servicesservices

Wrong SiteWrong Site, Wrong Patient Surgery, Wrong Patient Surgery Incompatible bloodIncompatible blood transfusion, hemolytic reaction transfusion, hemolytic reaction

incompatible bloodincompatible blood Death from hospital infectionDeath from hospital infection or major permanent or major permanent

loss of function associated with health-care acquired infectionsloss of function associated with health-care acquired infections Rape Rape Retained foreign objectRetained foreign object unintended retention of a in an unintended retention of a in an

individual after surgery or other procedure individual after surgery or other procedure Adverse Patient OccurrencesAdverse Patient Occurrences warranting expanded warranting expanded

investigationinvestigation

What Must We Do?What Must We Do? Create Culture of Create Culture of

SafetySafety

Safety is at Safety is at the center of the center of all efforts!all efforts!

Safety is Everybody’s Safety is Everybody’s BusinessBusiness

Commitment and Commitment and participation of ALL participation of ALL employees and staffemployees and staff

Leadership Safety Leadership Safety WalkaroundsWalkarounds

What Else Should We What Else Should We Do?Do?

Encourage error reporting in a Encourage error reporting in a Non-punitive systemNon-punitive system Help staff understand risk, accept Help staff understand risk, accept

responsibility for harm, lead efforts to responsibility for harm, lead efforts to prevent harmprevent harm

Recognize errors as opportunities for Recognize errors as opportunities for reducing riskreducing risk

Teach staff how error reports help to Teach staff how error reports help to track/trend safety issues and improvement of track/trend safety issues and improvement of processesprocesses

Don’t tolerate cover-ups Don’t tolerate cover-ups Support employees involved in serious errorsSupport employees involved in serious errors Perform Root Cause Analyses whenever Perform Root Cause Analyses whenever

indicatedindicated

Why Is This Hard ?Why Is This Hard ?

Trained to be perfect Trained to be perfect —— knowledge knowledge and competence are equated with the and competence are equated with the absence of errorabsence of error

Medical culture rewards perfection Medical culture rewards perfection and frowns upon errorand frowns upon error

Individual agency Individual agency —— fix the person fix the person and the problem goes awayand the problem goes away

Don’t Forget to Improve Don’t Forget to Improve Communication and Team Communication and Team

WorkWork Focus on common goal of safe patient careFocus on common goal of safe patient care Promote teamwork trainingPromote teamwork training Standardize Communication (SBAR)Standardize Communication (SBAR) Apply Crew Resource Management techniquesApply Crew Resource Management techniques

Use 3Use 3rdrd person when communicating “WE” person when communicating “WE” Develop checklists Develop checklists

Hand-offs, proceduresHand-offs, procedures Initiate teamwork training in professional schools, Initiate teamwork training in professional schools,

residency programsresidency programs

Of Course, Include Patients Of Course, Include Patients and Families in Patient and Families in Patient

SafetySafety Empower patients Empower patients

and families to and families to actively participate actively participate in care in care

Include patients and Include patients and families on safety families on safety teams, in safety walk teams, in safety walk aroundsarounds

Establish patient Establish patient advocacy groups to advocacy groups to advise leadersadvise leaders

Of Course, Include Patients Of Course, Include Patients and Families in Patient and Families in Patient

SafetySafety Empower patients Empower patients

and families to and families to actively participate actively participate in care in care

Include patients and Include patients and families on safety families on safety teams, in safety walk teams, in safety walk aroundsarounds

Establish patient Establish patient advocacy groups to advocacy groups to advise leadersadvise leaders

Measure Results and Measure Results and Monitor ProgressMonitor Progress

CMS Quality Metrics CMS Quality Metrics www.www.cmscms.hhs.gov/.hhs.gov/qualityquality/hospital/PremierMeasures/hospital/PremierMeasures AHRQ Patient Safety Indicators AHRQ Patient Safety Indicators www.ahrq.orgwww.ahrq.org JCAHO National Patient Safety Goals JCAHO National Patient Safety Goals www.jcaho.orgwww.jcaho.org IHI 100,000 Lives Campaign IHI 100,000 Lives Campaign www.ihi.orgwww.ihi.org NQF safe practices NQF safe practices www.qualityforum.orgwww.qualityforum.org National Patient Safety Foundation National Patient Safety Foundation www.npsf.orgwww.npsf.org Leapfrog initiatives Leapfrog initiatives www.leapfroggroup.orgwww.leapfroggroup.org FMECA FMECA www.jcaho.orgwww.jcaho.org Internal and External Benchmarks Internal and External Benchmarks www.qiproject.orgwww.qiproject.org www.nursingquality.orgwww.nursingquality.org

What Hinders a Patient What Hinders a Patient Safety Program?Safety Program?

Hierarchy / power distanceHierarchy / power distance Failure to communicateFailure to communicate Lack of common mental modelLack of common mental model Not having a voiceNot having a voice Lack of respectLack of respect Fear of retributionFear of retribution

Up, Up, and Away with Up, Up, and Away with Patient SafetyPatient Safety