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Meeting the
Critical
Challenge to
Ensure Patient
Safety & Quality
Glenda M. Payne, MS, RN, CNN
Director of Clinical Services
Nephrology Clinical Solutions
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Objectives
1. Describe common risks to the
safety of dialysis patients
2. Examine ways to use quality
improvement techniques to decrease
risks and improve the quality of care
delivered
3. Discuss initial steps to implement
a facility based program to improve
quality and safety
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Risks to Patient Safety:
Medical Errors
• Medical errors in the US result in an
estimated 44,000 to 98,000 unnecessary
deaths >1,000,000 instances of harm each
year.
• A 13.5% level of harm was identified within
the US Medicare population
Institute of Healthcare Improvement (IHI)
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Cost of Medical Errors
• According to the Institute of Medicine,
medical errors add $17 to $29 billion per
year to the costs of healthcare in the US.
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Most Common Causes of
Patient Injuries
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Wrong site surgery
Medication errors
Healthcare acquired infections
Falls
Readmissions
Diagnostic error
National Patient Safety Foundation (NPSF)
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Most Common Patient Injuries:
Potential in ESRD
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Wrong site surgery
Medication errors
Healthcare acquired infections
Falls
Readmissions
Diagnostic error
National Patient Safety Foundation (NPSF)
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Preventing Medication Errors in ESRD
• Refocus routine “home med” reviews:
make medication reconciliation a priority
• Medication changes happen:
– With physician office visits
– With “secondary” illness
– With hospitalizations
– With ER visits
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Medication Errors in ESRD
Protocol driven medications: risk for errors?
• Standard routine for changes?
• Is the “driver” individualized care?
Other potential “medication” errors:
• Heparin
• Saline
• Water/Dialysate
• Dialysis prescription
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Healthcare Acquired Infections in
ESRD
• To lessen this risk:
• Vaccinations
• Infection control
– Active monitoring program
– Patient education
– Staff education
– Practice audits
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Reducing the Risk for Falls
• Risk assessment
– On admission
– With each reassessment
– With any change in patient cognition or
mobility
• Implement measures to protect patients at
higher risk
• Remove environmental hazards
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Reduce the Risk of Hospital Readmissions
• Reassess after hospital discharge
• Revise the patient plan of care (POC) as
needed
• Medication reconciliation
• Address changes in function, cognition,
mobility
• Involve patient support system
• It takes a TEAM…
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Diagnostic Errors in Dialysis
• Think fluid management…
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How Do You Make Your Facility Safer?
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Staff orientation
Staff training
Competency testing
Continuing education
Audits of practice
Patient education
Routine PE inspection
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Other Ways to Prevent Patient Injury
Build in Safety:
• Product ordering/ receipt of supplies
• Systems design
“Human factors” design: the
study of all aspects of
the way humans relate to
the world around them,
with the aim of improving
performance and safety
Wikipedia
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Human Factors Design
• Do you store heparin near lidocaine?
• Do you store different strengths of heparin
near one another?
• Do you fill jugs with different acid
concentrations—while all the jugs are on
the same cart?
• How can you design your work space so
that errors are less likely to occur?
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HOW TO BUILD A
CULTURE OF SAFETY
IN YOUR FACILITY
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Quality Improvement
Constant Process
Plan
Act
Patient Safety
Do
Study
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Involve the Whole Team In QAPI
Use key staff members to:
• Identify safety issues
• Formulate solutions
• Test those solutions
• Implement the best solution
• Measure outcomes in order
to improve patient safety
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Too Many Of Us Never Get Above Data…
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Effective QAPI
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Cannot improve what you do not measure
Takes at least three “points” to see a trend
Data is meaningless without analysis
If you don’t document it, you didn’t do it
(and you won’t remember it next month!)
• Make a plan, implement the plan, evaluate
effectiveness, repeat
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Root Cause Analysis
• Use an interdisciplinary team
• Include the most expert frontline
staff
• Include those most familiar with the
situation
• Use an impartial process
• Goal: identify changes that need to
be made to systems
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Focus On The Why & How, Not The Who
Root Cause
Why
Why
How
Why
How
Why
How
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Prevention Not Punishment
The goal should be to find out:
• What happened
• Why did it happen
• What to do to prevent it from happening
again
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Target Systems, Not People
• “Name and blame” culture allows
underlying systems-based problems to be
ignored and not addressed
• In “no blame” cultures, near misses are
reported and learned from: leading to
continuous quality improvement and safer
environments for patients
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Patient Exposure to Chlorine
Swiss Cheese Model
steps
latent errors
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Can Never Eliminate All Errors
• Critical to design systems that are “fault
tolerant”, so that when an individual error
occurs, it does not result in harm to a
patient
VA National Center for Patient Safety
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Patient Safety Program
Assess
•Inspect facility
for hazards
•Evaluate staff
competency
•Determine med
error rate
•Determine
infection rate
•Evaluate patient
engagement
Plan
•Develop facility
PE monitoring
tool
•Develop staff ed
•Develop med
error reduction
plan
•Develop IC
guidance
•Develop patient
education
Repeat
Implement
•Routinely
monitor PE
•Educate staff
•Implement
med error
reduction plan
•Implement IC
plan
•Educate
patients
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But I’m Just One Person…
Most errors are the result of failures related
to:
• Assumptions
• Presumptions
• Communication
On your own, you can improve each of
these areas!
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Assumptions and Presumptions
• “Assume” that every medication you are
responsible for is potentially lethal: build in
multiple check points to be sure the med is
“right” for this patient
• Presumptions: routinely question
presumptions—don’t presume someone
has tested the water…or that the patient
coming back from hospital has the same
target weight as before
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Communication: The Hardest Thing
• “Basic rule in human communication: if it
can be misread, misunderstood,
misinterpreted, misqualified, or just plain
missed, it will be.”
Nance. 2008. Why Hospitals Should Fly
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Learn To CUS
• Concerned/ Uncomfortable/ Safety
• “I’m concerned about Ms. Jones’ dry
weight. She just returned from the hospital
and her records say she was coming off at
63 kg. there. I’m uncomfortable trying to
take her much lower than 63 kg, and am
not sure it is safe to try to take her weight
down to 59 kg. now.
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Thanks for the Work You Do!
[email protected]
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