Download Patient Wrongs

Preventing Patient Harm through Handoffs and
Huddles
Michelle George, RN MSN CASC
1
Agenda
1.
Objectives
2.
Review of ASC clinical outcomes trends
3.
Role of communication in patient safety
4.
Hand off communication
5.
Huddles
6.
Wrap up
7.
Questions
2
Objectives
• Review patient harm events that can occur in the ASC setting
• Identify 3 different methods for effective handoff from caregiver to caregiver
• Describe the key principles of an effective perioperative team huddle
• Identify effective strategies for engaging members of the healthcare team in
targeted patient care communications
3
Agenda
1.
Objectives
2.
Review of ASC clinical outcomes trends
3.
Role of communication in patient safety
4.
Hand off communication
5.
Huddles
6.
Wrap up
7.
Questions
4
ASC Industry Clinical Outcomes Trends
1.8
Patient Falls
0.4
0.4
Rate Per 10k Cases
Rate Per 10k Cases
1.6
1.4
1.2
1.0
0.8
0.6
0.3
0.3
0.2
0.2
0.4
0.1
0.2
0.1
0.0
0.0
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
'10 '10 '11 '11 '11 '11 '12 '12 '12 '12 '13 '13 '13 '13 '14
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
'10 '10 '11 '11 '11 '11 '12 '12 '12 '12 '13 '13 '13 '13 '14
Patient Wrongs
0.5
0.5
0.4
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.0
Patient Transfer
14.0
12.0
Rate Per 10k Cases
Rate Per 10k Cases
Patient Burns
10.0
8.0
6.0
4.0
2.0
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
'10 '10 '11 '11 '11 '11 '12 '12 '12 '12 '13 '13 '13 '13 '14
Note: ASC Quality Collaboration data source
0.0
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
'10 '10 '11 '11 '11 '11 '12 '12 '12 '12 '13 '13 '13 '13 '14
5
Agenda
1.
Objectives
2.
Review of ASC clinical outcomes trends
3.
Role of communication in patient safety
4.
Hand off communication
5.
Huddles
6.
Wrap up
7.
Questions
6
Healthcare Harm: Slips, Trips and Falls
Patient harm can occur even when policies & procedures and safety standards have
been adopted
7
Healthcare Harm: Surgical Burns
Patient harm usually involves commonly used equipment and procedures that are
performed on a routine basis
Photo Source:
http://www.bing.com/images/search?q=medical+errors+surgicalburn
8
Factors in Patient Harm Events
• Emotional: Can create feeling of being overwhelmed for the patient, family and
the healthcare team
• Physical: May involve equipment and/or disposable items that need to be
sequestered
• Environmental: Team not always alerted by smells, alarms, smoke and other
warnings
• Political: Egos and opinions can be distracters from the facts during safety
breaches
• Legal: Company values and policies regarding full disclosure, integrity and
commitment to seek resolution serves as the guide through risk management
processes
9
Communication Issues Leading Factor in Root Causes
Collation of sentinel event-related data reported to The Joint Commission (1995-2005). Available
http://www.jointcommission.org/SentinelEvents/Statistics/
10
Communication Facts
• Root cause in majority of patient sentinel events
• Miscommunications result in lost information, misinterpretations, and missed
actions
• Plays role in duplication and omission medication errors
• Patient Harm events--direct correlation to communication breakdown during
patient hand-offs
• Culture issues can lead to failure to speak up
• Perioperative setting at high risk due to complex technology complex, involves
multiple disciplines, fast paced, and dynamic circumstances
11
Agenda
1.
Objectives
2.
Review of ASC clinical outcomes trends
3.
Role of communication in patient safety
4.
Hand off communication
5.
Huddles
6.
Wrap up
7.
Questions
12
Hand Off Communication
Improve patient
care by targeting
patient handoffs!!
13
Perioperative Continuum of Care
Surgeon’s
Office
OR
Scheduling
PostOp Visit
Discharge
Phase
Registration
PreOp
Assessment
PACU
OR/
Procedure
Room
14
Hand Off Communication Tools
• Provides structure to
communication
• Shared model ensures consistency
• Ensure that key information is
shared
• Numerous established tools
available
• Can be used to improve
performance
• Requires staff education and
practice
15
Hand Off: “5 Ps”
• Ensures consistent information is passed during patient transfers
• Easy mnemonic to remember
• Use the 5 Ps:
– Patient
– Plan
– Purpose
– Problems
– Precautions
16
Pre-Op
OR
• Planned surgical
Procedure
• Antibiotics to be
given
• Universal Protocol
• Significant medical
history
• Planned anesthesia
type
• Allergies
• Family contact
information
• Last voided
• Equipment needs
• Preop medications
• Other issues (e.g., NPO,
Courtesy of Tripler Army Medical Center. Adapted from OR Manager, April 2006.
blood products available)
OR
• Procedure
• Surgeon Plan and
Preferences (where we
are in the case)
• Anesthesia type
• Allergies
• Significant Medical
History
• Counts
Courtesy of Tripler Army Medical Center. Adapted from OR Manager, April 2006.
OR
• Irrigation
• Medications
• Instrumentation on
and off field
• Specimens on and
off field
• Equipment needs
• Tubes, Lines,
Hoses
OR Team
• Surgical procedure
(completed vs. planned)
• Anesthesia type
• Estimated Blood
Loss
• Input & Output
(e.g., straight catheter, foley)
• Allergies
• Medications (received intra-
PACU
• Significant medical
history (e.g., contact precautions)
• Family contact
information?
• Equipment needs
(e.g., sequential compression devices)
• Other issues (e.g., blood
op)
Courtesy of Tripler Army Medical Center. Adapted from OR Manager, April 2006.
products, anesthesia concerns)
SBAR Communication Model
S
Situation
Complaint, diagnosis, treatment plan and patient’s
wants and needs
B
Background
Vital signs, mental and code status, list of
medications and lab results
A
Assessment
Current provider’s assessment of the situation
R
Recommendation
Identify pending lab results and what needs to be
done over the next few hours and other
recommendations for care
20
Post It Style Communication Tool
21
Engaging the Team
SCA’s journey to create a fair and just culture where teammates feel empowered to
identify opportunities to improve patient safety and eliminate fear of reporting
events that compromise patient safety
• The Beginning:
– Emerging trend from Root Cause Analysis
– Patient safety culture survey results
• Purpose:
– Prevent healthcare harm from reaching the patient
– Shift culture from reactive to proactive
– Fully engage team (teammates and practitioners)
22
The Accountability Project
Implementation of multi-year program focusing on the prevention of patient harm
through enhanced communication and team engagement; rolled out as toolkit
Accountability Project I
• Focus on culture of safety
• Military-style Stand Downs for
teammates and physicians
• Do No Harm video and training
• Speak Up, Speak Out Campaign
• Individual and team commitment
to prevent patient harm
Accountability Project II
– Empowering communication
training
– Retaliation training
– Good Catch! Program to reward and
recognize team members for
identifying and mitigating nearmisses
– Repeat patient safety culture survey
• Perfect Time Out training
• Repeat patient safety culture
survey
23
Good Catch! Program
• Fun and interesting
baseball themed activities
• Increased awareness with
friendly competition
• Sustained engagement by
using playoff schedule
Center 1
Center 2
Center 3
Center 4
• Tracked and trended
“good catches” as PI study
focus
Center 5
• Individual and team
recognition with
certificates and plaques
Center 7
Center 6
Center 8
Center
Winner 1
Center
Playoff
Center
Winner 2
Regional
Champion
Center
Winner 3
Center
Playoff
Center
Winner 4
24
Hand Off Communication Strategies
• Determine the best structure for your facility—known tool or unique design
• Select the core content to include in hand-offs
• Determine who is responsible for initiating hand off communications
• Provide training to all team and practitioners
• Implement your hand off communication plan
• Engage patient and family when appropriate
• Leader rounding to determine effectiveness
• Assess hand off communications during near-miss and actual event Root Cause
Analysis
25
Agenda
1.
Objectives
2.
Review of ASC clinical outcomes trends
3.
Role of communication in patient safety
4.
Hand off communication
5.
Huddles
6.
Wrap up
7.
Questions
26
Key Principles of OR Huddles
• Proactive management of problematic situations
• Takes time and commitment to resolve problems
• Drives accountability
• Collaborative decision making process
• Provides a voice for every member
• Prevents safety issues which decreases cost and improves efficiency, safety and
satisfaction
• Inspires communication and team work and ultimately the end result is a high
standard of patient safety
27
Huddle Types
Early Morning Huddles
Afternoon Huddles
Special Huddles
Primary participants are the
clinical team members
Multidisciplinary
participation, usually the
same participants every day
Special circumstances
Review the plan for the day
Recap the day’s issues/
address root causes
Delays or add-ons in the
schedule
Address staffing for the day
Address schedule changes
(diabetics, pediatrics, gaps)
Out of order patients
Address management of comorbid conditions
Review cases for the next
day
Unanticipated staffing
changes
Collaborative work between
OR team members
Ensure equipment, implants,
vendors are ready for cases
Broken equipment or supply
outages
Reminder of upcoming
events—meetings,
inservices, deadlines, etc.
Plan for special patient
management issues
28
The Ultimate Huddle: Surgical Time Out
• All OR team members to participate
• Designated leader
• Performed immediately prior to the
procedure
• Stop all other activities
• Start over for any interruptions
• Address any special conditions or
needs
• Speak up for information or questions
• Do not proceed until all team is in
agreement
29
Strategies for Effective Huddles
• Determine the best meeting time for the team
• Assign a huddle leader
• Establish key issues to be addressed
• Provide the necessary training; retrain as needed
• Recognize team members for contributions
• Leader observations for effectiveness
• Trend results and share with the team
• Celebrate the prevention of patient harm
30
Agenda
1.
Objectives
2.
Review of ASC clinical outcomes trends
3.
Role of communication in patient safety
4.
Hand off communication
5.
Huddles
6.
Wrap up
7.
Questions
31
Wrap Up
1.
Assess quality of patient care communications
2.
Assess and determine need for safety culture shift
3.
Select a consistent approach to hand offs and huddles
4.
Educate teammates and practitioners
5.
Implement posters, signage, other supports
6.
Monitor effectiveness
7.
Share the findings with the team
32
Agenda
1.
Objectives
2.
Review of ASC clinical outcomes trends
3.
Role of communication in patient safety
4.
Hand off communication
5.
Huddles
6.
Wrap up
7.
Questions
33
Questions
34