Transcript Patient Safety Strategies for Improving Quality

Kelly Shipley, RHIA
QI Director
ESRD Network of Texas
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Distinguish the relationship between quality
and patient safety
Describe the steps in implementing a patient
safety program
Apply patient safety improvement tools in a
dialysis environment
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“Quality of care is the degree to which
health services for individuals and
populations increase the likelihood of
desired outcomes and are consistent
with current professional knowledge.”
Institute of Medicine
Quality = to Help
Safety = Do No Harm
Hippocrates “ As to diseases make a habit of two
things - to help, or at least, to do no harm.”
Epidemics I
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Cost of Quality
Cost of Errors
Formulas to show how actions can pay off
AC
AVERAGE COST
sum of event costs/number of events
BCR
BENEFIT-COST RATIO
cost avoided/cost of intervention
CER
COST-EFFECTIVENESS RATIO
cost of intervention/# of prevented events
CS
COST SAVINGS
(# of avoided events) X (average cost per
event) – (cost of intervention)
VHA,
Root Cause Analysis i& Improvement in the Healthcare Sector, ASQ
Medical Errors may be fifth
leading cause of death 1
Medical
Errors
Third
leading
cause of
death 2
Institute of Medicine/CDC 1997 1
JAMA, 2000 2
Tactics
Accountability
Support teamwork through “Crew
Resource Management”
Educators, medical staff, nursing
and health care leaders
Encourage appropriate adherence
to clinical guidelines to improve
quality & reduce liability risk
Medical staff & health care leaders,
medical processional societies,
health care purchasers & payers
Continue to leverage pt. safety
initiatives via regulatory/oversight
bodies
Accrediting, licensing & regulatory
bodies, PSO’s, purchasers & payers
Leverage the creation of cultures
Administrators, medical and
of patient safety in health care org. nursing leaders
P4P strategies provide incentives
to focus on improvements in pt.
safety & health care quality
CMS and private-sector healthcare
purchasers and payers
Health Care at the Crossroads: Strategies for Improving the Medical Liability
System and Preventing Patient Injury, Joint Commission
Safe
Equitable
Effective
Timely
Efficient
Patient -Centered
Crossing the Quality Chasm: A New Health System for the 21st Century, IOM
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Just Culture vs Blame or No Blame Culture
“People make errors, which lead to accidents. Accidents lead
to deaths. The standard solution is to blame the people
involved. If we find out who made the errors and punish
them, we solve the problem, right?
Wrong. The problem is seldom the fault of an
individual; it is the fault of the system. Change
the people without changing the system and the
problems will continue.” Don Norman, The Design of Everyday Things
The Just Culture Community, Nat’l Patient Safety Foundation
Patient Safety Culture
Where do we stand?
 Health & Safety Survey to Improve Patient Safety in ESRD
(RPA)
 Patients
 Professionals
 Hospital Survey on Patient Safety Culture - an assessment
tool from Agency for Healthcare Research and Quality
(AHRQ)
 Joint Commission, Leapfrog Survey, NQF
 Discussing & Reporting Events
Near Miss, Close Calls, Sentinel Events,
Adverse Events
Mandatory versus voluntary reporting
Disclosure
RPA, March 2007
SECTION C: Communications
How often do the following things happen in your work area/unit? Mark your answer
by filling in the circle.
Think about your hospital work area/unit…
1. We are given feedback about changes put into place based on
event reports
2. Staff will freely speak up if they see something that may
negatively affect patient care
3. We are informed about errors that happen in this unit
4. Staff feel free to question the decisions or actions of those with
more authority
5. In this unit, we discuss ways to prevent errors from happening
again
6. Staff are afraid to ask questions when something does not seem
right
Most of
the
time
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Alway
s
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Never
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Rarely
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Sometimes
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(a) Standard: Program scope.
(1) The program must include, but not be limited
to, an ongoing program that achieves measurable
improvement in health outcomes and reduction of
medical errors by using indicators or performance
measures associated with improved health
outcomes and with the identification and reduction
of medical errors.
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(2) The dialysis facility must measure, analyze, and
track quality indicators or other aspects of
performance that the facility adopts or develops
that reflect processes of care and facility
operations. These performance components must
influence or relate to the desired outcomes or be
the outcomes themselves. The program must
include, but not be limited to, the following:
(vi) Medical injuries and medical errors
identification.
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(c) Standard: Prioritizing improvement
activities. The dialysis facility must set
priorities for performance improvement,
considering prevalence and severity of
identified problems and giving priority to
improvement activities that affect clinical
outcomes or patient safety. The facility must
immediately correct any identified problems
that threaten the health and safety of
patients.
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Assess
◦ Leadership Commitment
◦ Current environment
◦ Have to or want to?
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System
◦ Who, What, When, Where, How
◦ Flowchart
◦ Data Management
 Reporting, Responding, Proactive vs Reactive Analysis
 Improvement
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Communication
◦ Training, Education
◦ Patient Involvement
◦ Disclosure
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Resources
Patient involvement examples
Disclosure
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Concepts –
◦ Sharp end vs Blunt end
◦ Swiss Cheese Model
◦ Human Behavior Model
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Analysis
◦ Root Cause Analysis (RCA)
◦ Failure Modes Effects Analysis (FMEA)
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Hardwiring for safety
◦ Reminder Systems vs Equipment Design
◦ Checklists
◦ CQI Tools
Sharp-Active
 Error Categories
 Active Errors or Failures
 Point of contact with patient
 Generally readily apparent
 Involve frontline staff
 Sharp End errors
Blunt-Latent
 Latent Errors or Conditions
 Less apparent failures that contribute to error
downstream
 Removed from direct patient care – processes
that support care
 Blunt End errors
Medication Administration
Sharp End Active Failures
•nurse administers wrong med
•nurse administers med to wrong
patient
•anesthesiologist administers wrong
drug through unlabeled syringe
Blunt End Latent Failures
• incomplete pt info
•unclear communication of drug order
•no independent double checks
•lack of computer warnings
•drug storage issues
•unclear policies & procedures
Sharp End:
Immediate
Cause(s)
Contributing
Factors
Blunt End:
Root Cause(s)
Complex System Latent Failure
Model
LATENT
FAILURES
Triggers
The
World
Accident
DEFENSES
Were the
actions as
intended?
No
Yes
No
Were the
consequences
as intended?
Unauthorized
substance?
No
Knowingly
violate safe
operating
procedures?
Yes
Yes
Medical
condition?
Were procedures
available,
workable,
intelligible and
correct?
Yes
No
Pass
substitution
test?
No
Yes
No
Deficiencies in
training &
selection or
inexperience?
No
No
Yes
Yes
Yes
Sabotage,
malevolent
damage,
suicide, etc.
Substance
abuse
without
mitigation
Substance
abuse with
mitigation
Possible
reckless
violation
History
of unsafe
acts?
Systeminduced
violation
Possible
negligent
error
Systeminduced
error
Yes
Blameless
error but
corrective
training,
counseling
needed
No
Blameless
error
Diminishing
culpability
Decision Tree for Determining Culpability of Unsafe Acts
Reason, J., Managing the Risks of Organizational Accidents
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Process for identifying the basic or causal factors
that underlie variation in performance, including
the occurrence or possible occurrence of sentinel
events
A root cause is the most fundamental reason for
the failure of a process
The goal of RCA is to find out
◦ What happened?
◦ Why did it happen?
◦ What do you do to prevent it from happening
again?
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Focuses primarily on systems & processes, not individual
performance
Progresses from special causes in clinical processes to
common causes in organizational processes
Repeatedly digs deeper by asking “Why” Then, when
answered, asks “Why?” again and again
Identifies changes that could be made in systems & processes
that would reduce the risk of such events occuring in the
future
Is thorough and credible
Problem Statement:
You are on your way home from work and your car stops in the middle
of the road.
Why did your car stop?
1.
◦
Because it ran out of gas
Why did it run out of gas?
2.
◦
Because I didn’t buy gas on my way to work
Why didn’t you buy gas in the morning?
3.
◦
Because I didn’t have any money
Why didn’t you have any money?
4.
◦
Because I lost it all last night in a poker game
Why did you lose your money in last night’s poker game?
5.
◦
Because I’m not very good at “bluffing” when I don’t have a good hand
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Insert graph from JC of most common root
causes
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RCA reporting tool
Dialysis sent event & or near miss case
scenarios
(Audience participation)
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Action plan is key!
“A systematic, structured approach to
process improvement in the design
and process development stage
through identifying ways that a
process can fail, why it might fail, and
how it can be made safer.”
• Origin - aerospace industry in 1960’s
• Key tool for improving safety
• Goals: prevent defects, enhance safety,
increase customer satisfaction.
• Standardized approach
• Proactive approach vs. reactive response
• Another tool to add to your
PI toolkit
 Criteria:
 High Risk
 High Cost
 Problem Prone
 Low Volume
 Staff & Physician input, Committees
 Sources: Sentinel Event Alert, ISMP
 Industry news – Cedars-Sinai Hospital,
Christus Spohn Hospital South
Number of reported Sentinel Events related to Anticoagulants 1997 – 2007*
Drug Involved
#
Cause Of Event
#
Heparin
21
Wrong Drug
3
Warfarin
6
Wrong Dose
7
Enezapron
3
Improper Monitoring
9
Unknown
2
Pump Malfunction/Error
5
Outcome of Patients:
#
Given without order
2
Not reordered
2
Unknown
4
Death
Loss of Function
28
6
* Joint Commission SE database
Facilitator
 Team members closest to the process
 Content expert member(s), ad-hoc
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 Failure Mode: -ways in which a process
could break down or fail to perform
 Cause: why the failure mode occur
 Effect: what could happen if a failure mode
occurred
FAILURE MODE
EFFECT
•Wrong drug/route/form
of administration on physician order
•Inaccurate clinical data
B, T, D, ADR
•Wrong administration times selected
in Rx
•Delayed therapy; omission
•Misprogram pump
•Overdose; subtherapeutic dose B, T,
D, ADR
 Assign “Severity” rating – the consequence
of the failure should it occur.
 Assign “Occurrence” rating– the probability
or frequency of the failure occurring.
 Assign “Detection” rating – the probability
of the failure being detected before the
impact of the effect is realized.
Processe
s & Subprocesse
s
Failure
Modes
Causes
Effects
failure to
initiate
standard
order
set/prepri
nted order
no preexisting
order set,
not
followed/
don’t agree
w/protocols,
numerous
modification
s
therapy
may not
meet the
standard
of care
B,T,ADR, D
preprinted
orders
incomplet
e
no standard
process for
making
selections
on forms,
human
factors
therapy
may not
meet the
standard
of care,
wrong
drug/dose
ferquency
Severity
Rating
Occurrence
(Probability)
Rating
Detection
Rating
Critical
Index
A. Prescribing
Physician
prescribes
order
10
6
6
360
10
3
2
60
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Criticality Index (CI) score used
(severity rating x occurrence rating x detection rating)
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Evaluation of Failure Modes with High CI
◦ Order Failure Modes
◦ Preparing Drug
◦ Pump Failure Modes (programming, rate
changes, equipment design)
◦ Administration Documentation & Verification
Questions