Transcript Safety Behavior Education Design & Implementation

First, Do No Harm:
Building a Culture of Patient
Safety at Novant Health
Physician Education
Part 2: Safety Behaviors for Error
Prevention
First
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Goal and Objective
Goal:
Understand the Novant Safety Behaviors and commit
to making them personal work habits
Objective:
1. Provide an in-depth review of the five
organization-wide Safety Behaviors here at
Novant Health
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Our Novant Safety Behaviors &
Error Prevention Tools
1. Practice with a Questioning Attitude
A. Stop, Reflect & Resolve in the face of uncertainty
2. Communicate Clearly
A. Use SBAR-Q to share information
B. Communicate using three-way repeat backs and read backs
C. Use phonetic and numeric clarifications
3. Know & Comply with Red Rules
A. Practice 100% compliance with Red Rules
B. Expect Red Rule compliance from all team members
C. If compliance with a Red Rule is not possible, STOP action
until any uncertainty can be resolved
4. Self-check: Focus on Task
A. Use the STAR technique
5. Support Each Other
A. Cross-check and Assist
B. Use 5:1 Feedback to encourage safe behavior
C. Speak up using ARCC – “I have a concern”
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1. Practice with a Questioning Attitude
What should we do?
Think critically by questioning information we hear and
see if it doesn’t fit with what we know
Why should we do this?
– To detect incorrect information and assumptions that can
lead to erroneous decisions or actions
– To help ensure work activities are stopped when faced with
uncertainty or unsafe conditions
Error Prevention Tool
– Stop, Reflect and Resolve
Its not about asking
questions – its about
questioning the answers!
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Stop, Reflect and Resolve
Stop: Review the plan – do not proceed
in the face of uncertainty
Reflect: Does it make sense to me?
Technology
Patient
Resolve: Check it out with an
independent, expert source
Professionals
Medical Record
Documentation
Procedures &
References
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Reflect - An internal check
Our internal smoke detector…
Expectation
Current
Situation
• Does this make sense to me? Is it right, based on what
I know?
• Is this what I expected?
• Does this information “fit-in” with my past experience
or other information I may have at this time?
Get in the habit of asking these questions all the time…
it takes only seconds.
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Resolve - An external check
When should you resolve?
•
When your detector goes off
•
In every high-risk situation
•
When there is a change in the
patient condition or plan of care
It’s okay not to know…
It’s NOT okay not to find out.
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Our Novant Safety Behaviors –
Communicate Clearly
1. Practice with a Questioning Attitude
A. Stop, Reflect & Resolve in the face of uncertainty
2. Communicate Clearly
A. Use SBAR-Q to share information
B. Communicate using three-way repeat backs and read
backs
C. Use phonetic and numeric clarifications
3. Know & Comply with Red Rules
A. Practice 100% compliance with Red Rules
B. Expect Red Rule compliance from all team members
C. If compliance with a Red Rule is not possible, STOP action
until any uncertainty can be resolved
4. Self-check: Focus on Task
A. Use the STAR technique
5. Support Each Other
A. Cross-check and Assist
B. Use 5:1 Feedback to encourage safe behavior
C. Speak up using ARCC – “I have a concern”
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2. Communicate Clearly
What should we do?
Ensure that we hear things correctly and understand
things accurately
Why should we do this?
– To prevent wrong assumptions and misunderstandings
that could cause us to make wrong decisions
Error Prevention Tools
–
–
–
–
SBAR-Q to Transfer Information
3-Way Repeat Backs and Read Backs
Ask and Encourage Clarifying Questions
Phonetic & Numeric Clarifications
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SBAR-Q
An outline for planning and communicating information
about a patient condition or any other issue or problem
Situation:
What is happening right now?
Background:
What are the circumstances leading up to
this situation?
Assessment:
What do I think the problem is?
Recommendation: What should we do to correct the problem?
Questions:
Follow up questions?
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SBAR-Q: Questions
Encourage questions by inviting
questions and positively reinforcing
questions when asked
Asking a question is primarily an emotional security issue. We
can foster a culture of critical thinking by encouraging
questions. Invite questions, and use positive reinforcement
when questions are asked.
Top 3 Statements to Encourage Critical Thinking1
1. “What do you think?”
2. “That is an interesting question”
3. “Let’s explore this”
1Rubenfeld,
“Critical Thinking Tactics for Nurses”
A great way to help
break down perceived
Power Distance!
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Repeat Back / Read Back
1
Sender initiates communication using Receiver’s
Name. Sender provides an order, request or
information to Receiver in a clear and concise
format.
2
Receiver acknowledges receipt by a repeat-back of
the order, request or information.
3
Sender acknowledges the accuracy of the repeatback by saying, That’s correct! If not correct,
Sender repeats the communication.
Invite yourself in:
“Let me repeat that back…”
Train our ears to listen for
“That’s Correct!” – it’s a codeword
for “we understand each other”
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Clarifying Questions
Ask one to two clarifying questions:
– In all high risk situations
– When information is
incomplete
– When information is not clear
Why…
Asking clarifying
questions can reduce
the risk of making an
error by 2½ times!
How…
Use the Safety Phrase:
“Let me ask a clarifying
question…”
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Numeric Clarifications
For sound alike numbers,
say the number and then the digits…
15…that’s one-five
50…that’s five-zero
45…that’s four-five
425…that’s four-two-five
4 to 5…that’s the range four dash five
…and ALWAYS use leading zeros – as in 0.9
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Phonetic Clarifications
For sound alike words and letters, say the letter
followed by a word that begins with the letter…
A
B
C
D
E
F
G
H
Alpha
Bravo
Charlie
Delta
Echo
Foxtrot
Golf
Hotel
I
J
K
L
M
N
O
P
Q
India
Juliet
Kilo
Lima
Mike
November
Oscar
Papa
Quebec
R
S
T
U
V
W
X
Y
Z
Romeo
Sierra
Tango
Uniform
Victor
Whiskey
X-ray
Yankee
Zulu
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A Repeat Back Failure
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527
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“The Same”
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Our Novant Safety Behaviors –
Know & Comply with Red Rules
1. Practice with a Questioning Attitude
A. Stop, Reflect & Resolve in the face of uncertainty
2. Communicate Clearly
A. Use SBAR-Q to share information
B. Communicate using three-way repeat backs and read backs
C. Use phonetic and numeric clarifications
3. Know & Comply with Red Rules
A. Practice 100% compliance with Red Rules
B. Expect Red Rule compliance from all team members
C. If compliance with a Red Rule is not possible, STOP
action until any uncertainty can be resolved
4. Self-check: Focus on Task
A. Use the STAR technique
5. Support Each Other
A. Cross-check and Assist
B. Use 5:1 Feedback to encourage safe behavior
C. Speak up using ARCC – “I have a concern”
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3. Know and Comply with Red Rules
What Is A Red Rule?
An act having the highest level of
risk or consequence to patient or
employee safety if not performed
exactly, each and every time
“Red” designates the rule as a
safety absolute with the highest
priority for exact compliance
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Red Rules…For Times When
There Are No Do-Overs
Comair Flight 5191 crashed in Lexington, KY on
Sunday August 27, 2006. Of the 47 passengers and
3 crew, 49 people died.
The plane cleared for take off on Runway 22 but
taxied on the shorter Runway 26 instead. Not having
enough distance to take off, the plane crashes after
hitting a berm at the end of the runway.
Among the facts revealed by a January
NTSB release was the violation of the
"sterile cockpit" rule by the pilots, who
talked about their families, pets, and jobs
during taxi and takeoff.
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Novant Red Rules
1.
I will always verify patient
identity using 2 identifiers
prior to any treatment, therapy,
transport, procedure or
specimen draw.
2. I will always perform “double
checks” as specified by my
department*.
*Note: Refer to your department “Double-Check” poster for
your safety-critical double-checks
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Our Novant Safety Behaviors –
Self Check: Focus on Task
1. Practice with a Questioning Attitude
A. Stop, Reflect & Resolve in the face of uncertainty
2. Communicate Clearly
A. Use SBAR-Q to share information
B. Communicate using three-way repeat backs and read backs
C. Use phonetic and numeric clarifications
3. Know & Comply with Red Rules
A. Practice 100% compliance with Red Rules
B. Expect Red Rule compliance from all team members
C. If compliance with a Red Rule is not possible, STOP action
until any uncertainty can be resolved
4. Self-check: Focus on Task
A. Use the STAR technique
5. Support Each Other
A. Cross-check and Assist
B. Use 5:1 Feedback to encourage safe behavior
C. Speak up using ARCC – “I have a concern”
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4. Self Check – Focus on Task
What should we do?
Focus on the task at hand to avoid unintentional skillbased errors
Why should we do this?
– To avoid those slips or lapses where the hand is operating
before the head
– To reduce the chance that we’ll make an error when we’re
under time pressure, distracted or stressed
Error Prevention Tool
– Self Check Using STAR
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Self-Check Using STAR
Stop
Pause for 1 to 2 seconds to focus your
attention on the task at hand
Think
Consider the action you’re about to take
Act
Concentrate and carry out the task
Review
Check to make sure that the task was done
right and that you got the right result
STOP is the most important step. It gives your
brain a chance to catch up with what your
hands are getting ready to do.
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Our Novant Safety Behaviors –
Support Each Other
1. Practice with a Questioning Attitude
A. Stop, Reflect & Resolve in the face of uncertainty
2. Communicate Clearly
A. Use SBAR-Q to share information
B. Communicate using three-way repeat backs and read backs
C. Use phonetic and numeric clarifications
3. Know & Comply with Red Rules
A. Practice 100% compliance with Red Rules
B. Expect Red Rule compliance from all team members
C. If compliance with a Red Rule is not possible, STOP action
until any uncertainty can be resolved
4. Self-check: Focus on Task
A. Use the STAR technique
5. Support Each Other
A. Cross-check and Assist
B. Use 5:1 Feedback to encourage safe behavior
C. Speak up using ARCC – “I have a concern”
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5. Support Each Other
What should we do?
Look out for one other to catch each other’s mistakes while building a
greater sense of accountability for our actions
Why should we do this?
– To help everyone perform at their individual best
– To help our team perform at it’s best
Error Prevention Tools
– Cross Check and Assist
– Encourage Safe Behavior Using 5:1
– Speak Up for Safety Using ARCC – “I have a Concern”
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Cross-Checking in Healthcare
On your own, a person is only as reliable
as a human can be:
1 defect per thousand opportunities
Cross-checking multiplies the error probability:
0.001 x 0.001 = 1 defect per million opportunities
Malcolm Baldrige National Quality Award
High Reliability Organization (HRO) Lesson:
Together we are
Six Sigma quality (3.4 dpmo*)
* defects per million opportunities
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Encourage Safe Behavior Using 5:1
Encourage and praise others
when they use safe and productive behaviors
Constructively correct and give advice to
others
when they use unsafe and unproductive
behaviors
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Speak Up for Safety Using ARCC
Something I do to help our team prevent a safety event
Use the lightest touch possible…
Ask a question
Make a Request
Voice a Concern
If no success…
Use Chain of Command
A Safety Phrase – “I have a Concern…”
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A Speak up for Safety Failure
• DC-8 from Denver to Portland with 189 people
• While preparing to land, indications of unsafe landing gear extension
• National Transportation Safety Board (NTSB) findings
– Captain failed to properly monitor fuel state
– Captain failed to respond to crewmember’s advisories
regarding fuel state
– Crewmembers failed to successfully communicate fuel concern
to Captain
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Speak Up for Safety Using ARCC
Something I do to help our team prevent a safety event
Use the lightest touch possible…
Ask a question
Make a Request
Voice a Concern
If no success…
Use Chain of Command
A Safety Phrase – “I have a Concern…”
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Our Goal – 80% Decrease in
Serious Safety Events
Current event rate, set at
100%
100%
Awareness
Event Rate
Skill Acquisition
80% Decrease
In Event Rate
Over 1-2
Years
Habit Formation
20%
Performance
Time
2 Years
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Novant Contact Information
•
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Sue DeCamp-Freeze
Senior Director Clinical Improvement
(704) 210-5767
[email protected]
•
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Catherine Fenyves
Patient Safety Manager
(704) 384-9329
Email: [email protected]
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