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Safety: It’s Everybody’s Business Virginia Ingram, MSN, RN [email protected] Patient Safety Officer University of Mississippi Medical Center Too fast….too far down the runway! “Most errors are made by good but fallible people, working in a challenged and imperfect system.” Error is Inevitable Because of Human Limitations * * * * Limited memory capacity – 5-7 pieces of information in short term memory Negative effects of stress – ↑ error rates Negative influence of fatigue and other physiological factors Limited ability to multitask – cell phones and driving Human Error is Also Inevitable Because: * * * Safety is often assumed, not assured Culture of the expert individual – mistakes not allowed AND……. Complex, unsafe systems THEN WE HAVE HUMAN JUDGMENT Oops! I forgot to set the Brake! Copyright © 1997-2005 AirDisaster.Com. All Rights Reserved. What can we learn from the Airline Industry? Before intervention, 70% of air crashes involved human error rather than failures of equipment or weather Crew Resource Management * * * Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making Non-punitive reporting of near misses Very open culture with regard to error and safety PATIENT SAFETY Without Safety, there is no Quality. What is Patient Safety? In its simplest form, patient safety is prevention of harm to patients. We are all in the business of Patient Safety!!!! The Legal Fallacy of the Low Risk Patient There are NO LOW RISK patients! Most medical legal claims come from low risk patients with poor outcomes ! IT STARTED WITH THE IOM REPORT NOVEMBER 1999 KEY FINDINGS: PREVENTABLE MEDICAL ERRORS CAUSE 44,000-98,000 DEATHS/YEAR IN U.S. ERRORS OCCUR BECAUSE OF SYSTEM FAILURES PREVENTING ERRORS MEANS DESIGNING SAFER SYSTEMS OF CARE JCAHO Patient Safety Goals Patient Identification Communication among caregivers Medication Safety Infusion Pumps Healthcare Acquired Infection Prevention Medication Reconciliation Falls Prevention Universal Protocol Labeling of Medications Clinical Alarms Sentinel Events Suicide of any individual receiving care or within 72 hours of discharge Abduction of any individual receiving care, treatment or services Wrong Site, Wrong Patient Surgery Incompatible blood transfusion, hemolytic reaction incompatible Death from hospital infection Rape Retained foreign object unintended retention of a in an individual Adverse Patient Occurrences warranting expanded investigation blood or major permanent loss of function associated with health-care acquired infections after surgery or other procedure What Must We Do? Create Culture of Safety Safety is at the center of all efforts! Safety is Everybody’s Business Commitment and participation of ALL employees and staff Leadership Safety Walkarounds What Else Should We Do? Encourage error reporting in a Non-punitive system Help staff understand risk, accept responsibility for harm, lead efforts to prevent harm Recognize errors as opportunities for reducing risk Teach staff how error reports help to track/trend safety issues and improvement of processes Don’t tolerate cover-ups Support employees involved in serious errors Perform Root Cause Analyses whenever indicated Why Is This Hard ? Trained to be perfect — knowledge and competence are equated with the absence of error Medical culture rewards perfection and frowns upon error Individual agency — fix the person and the problem goes away Don’t Forget to Improve Communication and Team Work Focus on common goal of safe patient care Promote teamwork training Standardize Communication (SBAR) Apply Crew Resource Management techniques Use 3rd person when communicating “WE” Develop checklists Hand-offs, procedures Initiate teamwork training in professional schools, residency programs Of Course, Include Patients and Families in Patient Safety Empower patients and families to actively participate in care Include patients and families on safety teams, in safety walk arounds Establish patient advocacy groups to advise leaders Of Course, Include Patients and Families in Patient Safety Empower patients and families to actively participate in care Include patients and families on safety teams, in safety walk arounds Establish patient advocacy groups to advise leaders Measure Results and Monitor Progress CMS Quality Metrics www.cms.hhs.gov/quality/hospital/PremierMeasures AHRQ Patient Safety Indicators www.ahrq.org JCAHO National Patient Safety Goals www.jcaho.org IHI 100,000 Lives Campaign www.ihi.org NQF safe practices www.qualityforum.org National Patient Safety Foundation www.npsf.org Leapfrog initiatives www.leapfroggroup.org FMECA www.jcaho.org Internal and External Benchmarks www.qiproject.org www.nursingquality.org What Hinders a Patient Safety Program? Hierarchy / power distance Failure to communicate Lack of common mental model Not having a voice Lack of respect Fear of retribution Up, Up, and Away with Patient Safety