Taking Care of Patients Safely

Pitt County Memorial Hospital

Let’s not learn patient safety by accident…



Willie King

, age 51 with a history of diabetes, consented to a have a below knee amputation on his right foot. Surgeons amputated is left foot in error.

 Prior to surgery, Willie joked with the medical staff, “You know which one it is, don’t you? I don’t want to wake up and find the wrong one gone.” Slide 2

Let’s not learn patient safety by accident…



Joan Faulkner

was badly burned in a hospital in North Carolina when a cauterizing tool ignited the oxygen that she was receiving during a routine surgical procedure. Her top lip was burned off, her face, neck and chest suffered 2 nd and 3 rd degree burns.

Slide 3

The Costs of Mistakes

 The Institute of Medicine estimates 44,000 to 98,000 deaths occur each year due to medical errors  An additional 100,000 deaths occur each year from hospital-acquired infections, half of which were preventable  Probability of a patient dying in a hospital due to an human error is 1 in 300.

Slide 4

These types of errors can happen at any hospital!

Slide 5

Learning About Human Error

Slide 6

Why Do Events Happen?

Sometimes an error occurs, but an event or injury is prevented by an internal system of checks

Significant events or injuries

Sometimes multiple errors line up to allow a significant event or injury to occur From

Managing the Risks of Organizational Accidents

, James Reason Slide 7

Human Error Classification

There are 3 major categories of errors

   Skill-based errors Rule-based errors Knowledge-based errors Slide 8

Human Error Classification

Skill-Based Errors

Errors made when performing acts or tasks while utilizing skills on “auto pilot” Skill-based errors most often occur during lapses in attention (e.g. when we’re pressed for time, or when the action is so routine we don’t pay attention).

Slide 9

Human Error Classification

Rule-Based Errors

Errors made when performing acts or tasks that require application of rules accumulated through experience and training    Types of Rule-Based Errors Wrong Rule Misapplication of Correct Rule Non-Compliance with Rule Slide 10

Human Error Classification

Knowledge-Based Errors

Errors made when performing acts related to new or unfamiliar situations that require problem solving or when a rule does not exist or is unknown to the performer   Types of Knowledge-Based Errors Decision-making Problem solving Slide 11

Behavior Based Expectations & Tools to Assist in the Reduction of Errors

Behaviors for Physicians

1. Pay Attention to Detail Self-check using STAR 2. Communicate Clearly 3. Handoff Effectively Repeat-back Clarifying questions Phonetic/numeric clarification SBAR SBAR 4. Support Each Other Speak-Up/Listen using AAA Encourage questions

Slide 13

BBE #1: Pay Attention to Detail

Focus attention to always think before we act.

Why should we do this?

  To avoid unintended

slips or lapses

To reduce the chance that we’ll make an error when we’re under time pressure or stress

When should we do this?

 Before we act, speak, and document Slide 14

Error Prevention Tool

Self Checking Using STAR

S top: T hink: A ct:

Pause for 1 to 2 seconds to focus on what you’re about to do Think about what you’re about to do – focus on the action Concentrate and perform the task

R eview:

Check to see if the task was done right Slide 15

BBE #2: Communicate Clearly

Communicate correct information in a timely and appropriate manner.

Why should we do this?

 To ensure that we

understand hear

things correctly and that we things correctly  To prevent avoid wrong assumptions and misunderstandings that could cause us to make wrong decisions

When should we do this?

Whenever we communicate information – either in person or over the phone – that could affect the care and safety of a resident or an employee Slide 16

Error Prevention Tool

3-Way Repeat Backs

When information is transferred...

1 2 3 Sender initiates

communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear and concise format.

Receiver acknowledges

receipt by a repeat back of the order, request, or information.

Sender acknowledges the accuracy

of the repeat-back by saying,

That’s correct!

If not correct, Sender repeats the communication.

Slide 17

Error Prevention Tool

Clarifying Questions

Ask 1 to 2 clarifying questions

When in

high risk

situations When information is

incomplete

When information is

ambiguous WHY:

To reduce the probability of making a wrong assumption. Asking clarifying questions reduces the risk by 2 1/2 times!!

HOW:

Phrase your clarifying questions in a positive way and in a manner that will get an answer that improves your understanding of the information Slide 18

I A B C D E F G H

Error Prevention Tool

Phonetic Clarifications

letter followed by a word that begins with the letter. For example: , say the letter followed by a word that begins with the letter. For example: Alpha Bravo Charlie Delta Echo Foxtrot Golf Hotel India J K L M N O P Q R Juliet Kilo Lima Mike November Oscar Papa Quebec Romeo S T U V W X Y Z Sierra Tango Uniform Victor Whiskey X-Ray Yankee Zulu Slide 19

Error Prevention Tool

Numeric Clarifications

For

sound alike numbers

, say the number and then speak each digit of the number. For example: 15…that’s one-five 50…that’s five-zero Slide 20

BBE #3: Handoff Effectively

Handoff patients or tasks by giving appropriate information and ensuring understanding and ownership.

Why do we have this behavior?

 To ensure that complete and accurate information about the patient, project, or task is communicated when responsibility transfers from one individual to another

When should we practice this behavior?

 When turning responsibility for a patient, project, or task to another individual Slide 21

Error Prevention Tool

SBAR for an Effective Handoff

When transitioning care to another physician, or when requesting a consult on a patient, use the SBAR technique to organize your communication S ituation:

Describe the situation, patient or question

B ackground :

Highlight the important information, precautions, issues

A ssessment :

Outline your read of the situation, problems and precautions

R ecommendation :

State your recommendation, request or plan Slide 22

BBE #4: Support Each Other



Speak Up for Safety by using the Triple A technique

A sk (Do you think we should order a CXR?) A dvocate (I think we need to order a CXR.) A ssert (I’m concerned that we may miss something if we don’t get a CXR.)  Tips Use the lightest touch possible… When asserting, use the safe word: “concern” If not successful and you’re still worried, then use chain of command Slide 23

Encourage Questions

Encourage questions by inviting questions and positively reinforcing questions when asked.

Asking a question is an emotional security issue. 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 Thinking 1 1. “What do you think?” 2. “That is an interesting question” 3. “Let’s explore this” 1 Rubenfeld, “Critical Thinking Tactics for Nursing” Slide 24