Transcript Creating a Culture of Safety: Challenges in Ophthalmology
Creating a Culture of Safety: Challenges in Ophthalmology
James P. Bagian, MD, PE Director, Center for Health Engineering University of Michigan Founding Director, VA National Center for Patient Safety [email protected]
Ensuring Correct Surgical Care
• • • • • What was the objective?
What have we done?
How have we done?
What have we learned?
What remains to be done?
What Was The Objective?
• • Patient gets the best care possible • Diagnose and treat as intended No inadvertent harm • Incorrect surgery (aka Wrong-sided surgery) • SSI/HAI/DVT
What Have We Done?
• • Public & Professional Recognition of Problem • NQF, Joint Commission, AAOS, AAO, etc.
Guidelines, Regulations, etc.
• NQF Serious Reportable Events • Joint Commission National Patient Safety Goals • State, local, and organizational actions
NQF Serious Reportable Events
Joint Commission
Joint Commission
American Academy of Ophthalmology
• • Steps Prior to Day of Surgery • “clinic and surgery areas…specific data be passed between sites via written documentation rather than verbal” Steps On the Day of Surgery • “…proper eye should clearly be notated on the consent form. “ • “person who marks the eye should use written documentation with verbal verification” • Timeout – All team members, patient, side, implant, etc. Use “Hard Stop” if required
•
American Academy of Ophthalmology
Checklist for the Surgery Chart
• Pre-Op Area • Patient ID, Procedure, Side • Eye marked • Operating Room • Patient ID – name and birth date • Procedure & Side • Proper Implant – Style and Power • “Prior to draping, circulating nurse ensures that operative plan is visible
(post drape)
so that the surgeon can read it while gowned and gloved. “ • “The circulating nurse writes the patient's name, operative eye, IOL style, and IOL power on the white board. “
How Have We Done?
• Problems still exist
How Have We Done? - VA
• 2001-2006 Experience (All Specialties) • 108 OR adverse events
reported
• Ophthalmology and Orthopedics the highest
reports
although not most common procedures • Communication (inadequate timeout) and Patient Mis-Identification played major role • Wrong side >40% • Wrong Implant >30% • Wrong Site/Patient/Procedure each approx. 10%
Neily et al. Incorrect Surgical Procedures …Arch Surg 2009 Nov;144(11):1028-34
What Have We Learned? - VA
• • • Actions needed well before entering the OR • Timeout period is too late in many cases • Systems-based approaches beyond individual Involvement of all disciplines Structured communication that drives discussion • Briefings & debriefings,
Medical Team Training
essential
Supporting Long Term Memory
• Checklists • Put knowledge in the world vs. in the head • Recognition is better than recall • Checklist Philosophy • “Read and Verify” checklists • “Read and Do” checklists
Checklist-Driven Preoperative Briefing
Antibiotic Prophylaxis DVT Prophylaxis
Vertical Hierarchy
• “Silence Kills”. Team members uncomfortable “speaking up” when something does not seem right in a patient’s care, leading to patient harm.
• Poor communication between team members leading to a lack of situational awareness and a poor clinical decision resulting in patient harm.
• Did Medical Team Training (MTT) improve either of these baseline healthcare problems in our Organization?
Has MTT improved the Care of the Veteran?
• “Catches” in the Operating Room.
• Surgical morbidity and mortality.
Preventing Harm
144 Undesirable Events Prevented
June 1, 2009 MTT Update: 110 facilities
Improved OR Efficiency Following MTT
Following MTT . . .
63% Facilities reported improved equipment utilization.
54% Facilities documented improvement in “on time” starts of cases.
29% Facilities described reduced duration of operations.
MTT Status Update June 1, 2009, 110 Facilities.
Nursing Turnover Operating Room 10 8 6 4 2 0
P = 0.02
Pre
45 Operating Rooms and 35 Intensive Care Units Pre = 12 Months Prior to Learning Session Post = 12 Months Following Learning Session
Post
Outcomes – Morbidity / Mortality
Observed / Expected Mortality Ratios P = 0.03
Quarters of MTT 25
• • •
Summary - Gaps
Systems Approach
– Surgical issues must be dealt with in the extended peri-operative period, not solely in the OR • Entire system of care must be examined and engineered with desired results in mind – avoid unintended consequences • Patient Identification • Antibiotic Prophylaxis • DVT Prophylaxis •
Implant Use
Checklist-guided briefings and debriefings
•
Can’t rely on individuals being careful (vigilant)
Team Training
– start in initial training & sustain • More than SBAR – Leadership Must Be Involved