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