Download Handout - AmSECT

3/17/2016
Improved Patient Care and
Safety
David Fitzgerald, CCP, LP
Division of Cardiovascular Perfusion
College of Health Professions
Medical University of South Carolina
ARS Question #1
In my department/unit, we are actively doing
things to improve patient safety
Strongly agree
Agree
Neither
Disagree
Strongly disagree
ARS Question #2
When an event is reported, it feels like the person
is being written up, not the problem





Strongly agree
Agree
Neither
Disagree
Strongly disagree
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ARS Question #3
My supervisor/manager overlooks patient safety
problems that happen over and over





Strongly agree
Agree
Neither
Disagree
Strongly disagree
ARS Question #4
Staff will freely speak up if they see something
that may negatively affect patient care
 Always
 Most of the time
 Sometimes
 Rarely
 Never
ARS Question #5
When a mistake is made, but is caught and
corrected before affecting the patient, how often
is this reported?
 Always
 Most of the time
 Sometimes
 Rarely
 Never
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3/17/2016
Patient Safety
• Application of safety science methods
toward the goal of achieving a
trustworthy system of health care
delivery1
• An attribute of health care systems that
minimizes the incidence and impact of
adverse events and maximizes recovery
from such events1
• Patient safety is freedom from
healthcare associated, preventable
harm2
1- Emanuel L et al. http://www.ahrq.gov
2- http://www.evidenceintopractice.scot.nhs.uk/patient-safety/what-is-patient-safety.aspx
Patient Safety
• World Health Organization’s World Alliance for
Patient Safety
• Surgical Unit-based Safety Program (SUSP)
•
Surgical Site Infection control in Kenya and Uganda
• WHO Safe Childbirth Checklist
•
130 million births 303,000 mothers, 5.3 million children
die
• WHO Guidelines Safe Surgery
•
Surgical Safety Checklist
•
Pulse Oximetry Project
• Patient Safety in Robotic Surgery: SAFROS Project
• Global initiative for Emergency and Essential Surgical
Care
WHO: 10 Facts on Patient Safety
1. Patient safety is a serious global public health issue
2. One in 10 patients may be harmed while in the hospital
(developing nations)
3. Hospital infections affect 14 out of every 100 patients admitted
4. Most people lack access to appropriate medical devices
5. Unsafe injections decreased by 88% from 2000 to 2010
6. Delivery of safe surgery requires a teamwork approach
7. About 20-40% of all health spending is wasted due to poorquality care
8. A poor safety record for health care
9. Patient and community engagement and empowerment are key
10. Hospital partnerships can play a critical role
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3/17/2016
• Purpose:
•
•
•
•
Chart 5-1. Composite-Level Average Percent Positive Response – 2014 Database Hospitals
Comparison
Assessment and Learning
Supplemental Information
Trending
• 42 Items that measure 12 composites of pt.
safety
•
•
•
•
•
•
•
•
•
•
Communication openness
Feedback and communication about error
Frequency of events reported
Handoffs and transitions
Management support for patient safety
Non-punitive response to error
Organizational learning- continuous improvement
Overall perceptions of safety
Staffing
Supervisor expectations and actions promoting
safety
• Teamwork across/within units
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Assessing the Culture of Safety in Cardiovascular
Perfusion:
Attitudes and Perceptions
Chad Lawson, Megan Predella, Allison Rowden, Jamie Goldstein,
Joseph J. Sistino, David C. Fitzgerald
Division of Cardiovascular Perfusion
College of Health Professions
Medical University of South Carolina
• Survey broadcasted through email invitation (Perflist, Perfmail and
LinkedIn)
• 37 closed, Likert-scaled questions based on AHRQ Hospital Survey on
Patient Safety Culture
• >75% agree or strongly agree
• “Overall work unit grade of patient safety”
Culture of Safety Highest Scoring Categories
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Culture of Safety – Lowest Scoring Categories
Joint Commission- 5 Principles of a Learning Organization
•
•
•
•
Team learning
Shared visions and goals
A shared mental model
Individual commitment to lifelong
learning
• Systems thinking
“Must have a fair and just safety culture,
a strong reporting system, and a
commitment to put data to work by
driving improvement”.
http://www.jointcommission.org/assets/1/6/PSC_for_Web.pdf
How to Promote Patient Safety
• Limiting Blame
• Fallacy: Well-trained and conscientious
practitioners do not make mistakes
• Systems Thinking
• Standardization and simplification
• Transparency and Learning
• Sharing information about medical
errors
1- Emanuel L et al. Available at: http://www.ahrq.gov
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How to Promote Patient Safety
• Culture and Professionalism
• “Collective mindfulness”- High-Reliability
Organizations
• Search for and report unsafe conditions before they
pose a substantial risk and when they’re easy to fix
• Accountability for Delivering Effective, Safe
Care
• Joint Commission- 20,000 centers accredit/certify
• Commitment to continuous learning / Published
literature
• Health Care as an Industry
• Partnerships
• Human factors engineering in health care
Annex 1 – Patient safety models
Two common models used to illustrate core concepts of patient safety are examined below:
The ‘Swiss Cheese’ model
James Reason’s Swiss Cheese model29 suggests each step in a process has weaknesses
which can lead to failure, including both individual errors and inherent weaknesses within a
system.
Reason’s model likens this to slices of Swiss cheese,
with the holes in the cheese representing potential
weaknesses. If a hazard arises, it can progress through
a hole in the first slice; that is, a weakness in the first
stage of the process will allow it to go unchecked. But
ideally, the hazard will encounter a solid section of
cheese in a subsequent slice, and progress no further;
i.e. one of the subsequent stages of the process will
identify the hazard and prevent it developing.
How to Promote Patient Safety
Figure 1: Patient Safety Swiss Cheese Model 30
• Rethinking Risk
• Quality improvement
• Risk management
However, if a system is set up in such a way that
holes in the cheese can become aligned across all slices, then a hazard could develop
unchecked, and eventual failure of the system is inevitable.
Therefore,
in Reason’s model,
I PASS THE
CLAMP OFF
maximising safety requires more slices, and smaller and fewer holes; i.e. more defence
stages across a model, and fewer and better-identified weaknesses
each stage,
Patient Handoff Toolat
for Perfusionists
minimising the aligned-weakness outcome. 31
I
P
A
S
The ‘Three Bucket’ model
Isolation precautions
Patient name/Procedure
contact, droplet, airborne
surgical approach, cannulation, backup plan,
target flows
Age/Allergies
medications, adverse reactions, associated
risks
Stage of the procedure
preoperative, perioperative, postoperative,
surgical status
Reason’s three bucket model 32 aims to help clinicians
take
an appropriate approach to
Status of temperature
S
considering their surrounding and limitations, so as
the degree of risk present,
Transfusion
T to estimate
History
and from a number of perspectives.
H
target temperatures, current temperatures,
rewarming rate
blood type, targets, product use, availability
• Emphasizing
symptoms, risk factors, diagnosis, prior
procedures, preoperative medications
E
C
model
Equipment condition
mechanical concerns or issues
oxygenator, tubing size and coating,
cardioplegia, shunts, hemoconcentrator,
accessories
Circuit
The
advises
staff to consider three areas
Lab values and targets
L
in which
risks
may be present – ‘Self’, ‘Context’
Anticoagulation
A
and ‘Task’
– and
in the model, illustrates these
Medications
M
as three
separate
buckets. At any one time,
Pump settings
P
eachObucket
beorfilled
Otherwill
conditions
concerns with a mixture of ‘Good
status
Stuff’Fand ‘Bad’Fluid
Stuff’;
and the overall risk of
error Fin a taskFinal
willthoughts
be in line with the total
amount of Bad Stuff present across all three
buckets.
hematocrit, blood gasses, electrolytes,
enzymes, targets
status, targets, heparin use, alternative
anticoagulants, blood components
Teamwork
vasoconstrictors, vasodilators, cardioplegia,
electrolytes, antiarrhythmics, colloids
FiO2, sweep, blood flow, vacuum, RPMs,
timers, shunts
jehovah’s witness, sickle cell anemia,
pregnancy, sepsis, DIC
• Relationships between
coworkers
I/Os, crystalloid use, ultrafiltrate amount
and rate, urine
Figure 2: Reasons Three Bucket Model
33
The NPSA have produced examples of factors which may be present in the three buckets 34;
e.g. in the Self bucket, knowledge, skill, expertise, as well as their current capacity. If
workload, fatigue and stress levels all increase, the Self bucket will contain more Bad Stuff,
and the risk of error rises.
All buckets are then considered. An example of this is given by McKimm & Forrest 35: if a
clinician
were to insert a of
cannula
to a compliant
patient with
large veins at the start of a day
Royal College of General PractitionersImplications
General
Practice
Workload
shift, they would not likely foresee any issues. But if the patient were uncooperative, and an
intravenous drug user with poor veins; it were the middle of the night; and the clinician were
tired, stressed and hungry, then ideally the clinician should stop and consider their three
‘buckets’ as being full, and so reconsider the task before deciding how best to proceed.
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Joint Commission Standard LD.04.04.05
The hospital has an organization-wide, integrated patient safety
program
• This standard describes a safety program that integrates safety priorities into all
processes, functions, and services within the hospital, including patient care,
support, and contract services. It addresses the responsibility of leaders to
establish a hospital-wide safety program; to proactively explore potential
system failures; to analyze and take action on problems that have occurred;
and to encourage the reporting of adverse events and near misses, both
internally and externally. The hospital’s culture of safety and quality supports
the safety program.
• At least every 18 months, the hospital selects one high risk process and
conducts a proactive risk assessment.
• At least once a year, the hospital provides governance with written reports on all
actions taken to improve safety, both proactively and in response to actual
occurrences
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3/17/2016
Identifying Risks
• Incident reports
• Near-misses
• Environmental tours
• Issues reported by Patient Safety Officer
• Observations by staff members
• Publications
• New regulatory issues
• Joint Commission Sentinel Events
• Product Recalls
• Audits, inspections
• Industry Standards and Guidelines
• Simulation exercises
• Time-outs, briefings, debriefings
• Failure Mode & Effect Analysis (FMEA)
Summary
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