Making A Title Slide

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Sharing and Learning How to Use Patient Safety
Morbidity Mortality Conferences to Achieve
Transparency and Promote a Culture of Safety
Prepared For National Patient Safety
Foundation Stand Up for Patient Safety
program March 19, 2008 Presented By Cynthia
Barnard, MBA, MSJS, CPHQ Marilyn Szekendi, PhD,
RN
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Our Discussion will Cover . . .

• The Goal A Culture of Safety
• The Patient Safety Morbidity Mortality
  Conferences
• How to
• Design
• Implement
• Use the findings
• Evaluate

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Northwestern Memorial HospitalChicago, Illinois

• 800-bed Academic Medical Center
• Nationally Recognized for Clinical Excellence
• Strong Tradition of Community Service
• Major Employer in City of Chicago
• New World-Class Facility Opened in 1999
• One of Two U.S. Hospitals with an AA Bond Rating

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Key Northwestern Memorial Hospital
StatisticsFiscal Year 2007

• Inpatient Admissions 43,855
• Patient Days 209,629
• Average Daily Census 591.9
• Average Length of Stay 4.78 days
• Deliveries 10,538
• Hospital Outpatient Registrations 477,065
• Surgical Cases Inpatient 12,137
• Surgical Cases Outpatient 18,758
• Emergency Department Visits 76,701
• Beds 744
• Medical Staff 1,545
• Employees 6,962

The number of beds increased to 897 with the
opening of the new Prentice Womens Hospital on
October 20, 2007.
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Pursuing a Culture of Safety
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What does a culture of safety look like?

• Organizational commitment to create and support
  safe systems
• Environment in which individuals feel free to
• identify errors
• openly question the safety of existing systems,
  and
• constructively analyze problems
• Errors are used for learning and for improving
• Hierarchies are flattened
• Transparency at all levels is encouraged

Dana-Farber Cancer Institute Principles of a Fair
and Just Culture, Dana-Farber Cancer Institute,
accessed at www.dana-farber.org/abo/news/tools/jus
tculture.asp.
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Who creates and exhibits a culture of safety?

• The environment for the culture is created by
  organizational leadership, which provides the
  atmosphere and opportunities for learning from
  error
• The culture is adopted by staff members at all
  levels of the organization, who respond to and
  benefit from the created environment

Wilkins BA. (2004). A brief summary of concepts
from nuclear energys work to develop a safety
culture. Inova Health System.
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High Reliability Organizations

• Preoccupation with failure
• Reluctance to simplify interpretations
• Sensitivity to operations
• Commitment to resilience
• Deference to expertise

Weick KE Sutcliffe KM (2001). Managing the
Unexpected Assuring High Performance in an Age
of Complexity. San Francisco Jossey-Bass.
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How Do You Know Whether You Have a Culture of
Safety?

• Incident reporting
• Interdisciplinary collaboration
• Walk Rounds
• Collegial rapid improvement projects
• Metrics such as AHRQ Hospital Survey on Patient
  Safety Culture (HSOPSC)

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National Challenges in Culture of Safety

• AHRQ Hospital Survey on Patient Safety Culture
  (HSOPSC)
• National Data 382 hospitals and 108,621 hospital
  staff respondents
• Highest scores for Teamwork Within Unit
• Lowest scores for Nonpunitive Response to Error
  the lowest average percent positive response (43
  percent), indicating this is an area with
  potential for improvement for most hospitals.
• The survey item with the lowest average percent
  positive response (35 percent) was "Staff worry
  that mistakes they make are kept in their
  personnel file" (an average of only 35 percent
  strongly disagreed or disagreed with this item).
  

Hospital Survey on Patient Safety Culture 2007
Comparative Database Report http//www.ahrq.gov/qu
al/hospsurveydb/hospdbch5.htm
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How can we promote and support a culture of
safety?For example . . .

• Create structure for the systematic review of
  safety concerns
• Establish care delivery practices that encourage
  teamwork and collegial relationships among
  members of different disciplines
• Institute human resource policies that support a
  non-punitive culture
• Create vehicles for sharing and learning from
  errors

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Patient Safety Morbidity Mortality Conference
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Patient Safety MM

• Created in 2003 to
• Openly identify and examine errors that occur in
  our hospital
• Perform a retrospective analysis (root cause
  analysis) with an interdisciplinary group
• Bring members of all disciplines together to
  share information and problem-solving efforts
• Bring lessons learned and solutions back to MM
  participants
• Encourage further event reporting

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Introducing the Idea and Initiating the
Conference

• Identify needed champions
• Ensure agreement on goals and process from other
  interested departments (e.g., Risk Management,
  Medicine, Nursing, Pharmacy)
• Establish organizational coverage for the MMs to
  maintain their status as quality initiatives
  according to your state law
• Identify needed resources (e.g., personnel for
  planning, meeting space, time allotment for staff
  to attend/complete)

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Patient Safety MMs Two Forums, Two Audiences

• 1. Interdisciplinary Patient Safety MM
• Monthly live conference, beginning at noon for
  one hour in large conference room that can seat
  up to 100 people
• Notice of conference sent via email each month
  interesting title
• Lunch served to attendees
• Nursing contact hours and ACCME credits for
  physicians offered for each program
• 2. Nursing Patient Safety MM
• Monthly online module completed by staff nurses
• Case study directly related to nursing care

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Interdisciplinary MM Monthly Meeting
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Interdisciplinary Patient Safety MMProgram
Organization

• Case study selected each month based on
• High priority recent events reported via incident
  reporting system
• Other events related to ongoing clinical care /
  safety initiatives within the organization (e.g.,
  falls, medication reconciliation, handoffs)
• On occasion, an event that occurred elsewhere,
  but could have happened at our hospital
• Panel is selected for each conference
• Panel members represent the disciplines involved
  in the actual event
• Typically physician, nurse, pharmacist
• May or may not have been actually involved in the
  event

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Program Agenda
1. Closing the Loop on Previous MM Findings

• Program begins with review of prior months case
  with key findings and recommendations from the
  MM participants

2. Presentation of Case Study
The case is read all audience members have a
hard copy for reference.
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Program Agenda

• 3. Discussion, Root Cause Analysis (VA National
  Center for Patient Safety model), and Plan for
  Improvement
• VA Root Cause Framework
• Human Factors Communication
• Human Factors Training
• Human Factors Fatigue/Scheduling
• Environment/Equipment
• Rules/Policies/Procedures
• Effective Barriers/Controls to Protect Patient
  Safety

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Example Interdisciplinary MM
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Sample MM Follow Up From Prior Month
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Sample MM Case Study for This Month

• JW is a 42 year old female who presented to the
  Emergency Department on 7-10-07 with
  complaints of fever, chills, right flank pain,
  and pain on urination. She was diagnosed with
  pyelonephritis, given a first dose of intravenous
  ciprofloxacin in the Emergency Department at 0100
  on 7-11, and admitted for continuation of
  intravenous antibiotics. The order for
  intravenous ciprofloxacin was placed as a
  pharmacy to dose order by the admitting
  physician. The order was verified by the
  pharmacist, but a dosed order was never entered.
  On the following day, 7-12, the patient
  complained of increasing abdominal pain so a CT
  scan was completed which revealed pyelonephritis.
  It was then discovered that the patient had not
  received any intravenous ciprofloxacin since the
  first dose in the Emergency Department. She
  received her second dose at 1800 that day
  (7-12), 41 hours after her first dose. Her pain
  improved and her white blood cell count began to
  fall. She was discharged home two days later.

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Sample MM Case Study Discussion Guide

• Triage Questions
• Were issues related to patient assessment a
  factor in this situation?
• Were issues related to staff training or staff
  competency a factor in this event?
• Was equipment involved in this event in any way?
• Was a lack of information or misinterpretation a
  factor in this event?
• Was communication a factor in this event?
• Were appropriate rules/policies/procedures or
  the lack thereof a factor in this event?
• Was the failure of a barrier designed to protect
  the patient, staff, equipment, or environment a
  factor in this event?

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Sample MM Case Study Discussion Guide

• Focus on the following six categories
• Human Factors Communication
• Human Factors Training
• Human Factors Fatigue/Scheduling
• Environment/Equipment
• Rules/Policies/Procedures
• Effective Barriers/Controls to Protect Patient
  Safety

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Interdisciplinary MM Evaluation
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Nursing Online MM
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Nursing MMProgram Organization

• Case study selected each month based on
• Relevance to nursing practice
• High priority recently reported events
• Other events related to ongoing clinical care /
  safety initiatives within the organization (e.g.,
  medication administration)
• On occasion, an event that occurred elsewhere,
  but could have happened at our hospital
• Online PowerPoint module created and posted
  online
• Nurses complete on their own
• Managers have 85 completion goal for their staff

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Example Nursing MM Module
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NMH Patient Care Division
Picture is for illustration purpose only

• Patient Safety
• Morbidity/Mortality Study Module
• Patient Identification
• November 2007

Exit
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Upon Completion . . .

• Participants will be able to
• Identify the importance of performing a thorough
  and accurate identification of any patient prior
  to providing any patient care service.
• State the required components of the patient
  identification process.
• Describe the unintended consequences of incorrect
  patient identification.
• Explain methods for improving patient
  identification procedures in their area of
  practice.

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Accurate Patient Identification

• The accurate identification of patients prior to
  the provision of care particularly the
  administration of medications or the performance
  of any invasive procedures is an important role
  of professional nurses in caring and advocating
  for their patients.

Picture is for illustration purpose only
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Case Study 1
Ray Williams, a 53 year old male, was scheduled
for a paracentesis in Interventional Radiology
(IR) on 09-04-07. When the IR staff were ready
to have the patient transported, they selected
the name of another patient, Roy Williams, in the
teletracking system. The transporter received
the request for Roy Williams and picked him up
and transported him to IR for the procedure.

Picture is for illustration purpose only
Roy Williams arrived in IR. In the holding area,
a nurse discovered that he was not the patient
scheduled for the procedure and he was returned
to his room. Mr. Williams was angry and
frightened by the error.
All names have been changed.
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Case Review

• 1. In case study 1, at what point(s) in the
  process were there errors or lapses in patient
  identification?
• A. Requesting the patient in the transport
  teletracking system
• B. Correct patient identification by the
  transporter in the patients room
• C. Identification of the patient by the
  transporter and the patients nurse on the
  inpatient unit (handoff)
• D. Identification of the patient by staff in the
  IR holding area
• E. A and C
• F. All of the above

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Case Review

• Great Job!
• In this case, the incorrect identification of the
  patient began when the IR staff selected the
  wrong patient name in the transport tracking
  system. The error continued unrecognized because
  the transporter and nurse on the inpatient unit
  had no communication prior to the patient being
  picked up and taken to IR. Had the nurse been
  contacted, she would have recognized that the
  patient being picked up was not scheduled for an
  IR procedure on that day.

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Case Review

• Incorrect. The correct answer is . . .
• A and C. In this case, the incorrect
  identification of the patient began when the IR
  staff selected the wrong patient name in the
  transport tracking system. The error continued
  unrecognized because the transporter and nurse on
  the inpatient unit had no communication prior to
  the patient being picked up and taken to IR. Had
  the nurse been contacted, she would have
  recognized that the patient being picked up was
  not scheduled for an IR procedure on that day.
• The transporter correctly identified the patient
  in his room and the nurse in the IR holding area
  also correctly identified the patient, leading to
  the discovery of the error.

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Nursing MM Evaluation

• Online survey conducted to obtain nurses
  assessment of Nursing MM
• Survey items taken from AHRQ HSOPSC survey
• 307 nurses responded, representing full range of
  clinical areas February March 2008
• Responses compared to hospital-wide HSOPSC
  culture survey responses for 716 nurses from May
  2006

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Nursing MM Survey Results
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Nursing MM Survey Results
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Nursing Feedback on MM Program
Many positive comments, but some constructive
criticism as well

• Nurses in Neonatal Intensive Care Unit and
  obstetrics brought to our attention that
• Scenarios are never geared towards
  maternal-fetal medicine.
• I feel like they never pertain to our unit.
• Would like to see some more neonatal specific,
  rather than adult based.

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Nursing Feedback on MM Program

• Some nurses preferred the original format, which
  involved case presentation and discussion at a
  staff meeting
• I think it was more beneficial when they were
  done by the manager.
• I like the way we used to do MMs, which was
  discussing as a group during staff meetings.

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Nursing Feedback on MM

• Favorable responses overall
• It is truly an eye opener to learn how mistakes
  are made and how NMH has come up with many safety
  tools and policies to prevent them.
• It is important to learn from actual cases that
  occur here at NMH and the MMs mostly help as
  refreshers to how we should be practicing and
  hopefully change people's bad habits.
• I think that it is a great idea to learn from
  mistakes that did occur. This teaches staff that
  it is human to err.

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Summary

• Patient Safety MMs have contributed to the
  creation of a culture of safety at Northwestern
  Memorial Hospital and have provided a valuable
  forum for the sharing of experiences, ideas, and
  problem solving among clinicians of multiple
  disciplines.
• We will continue to reinvent both programs
  based on feedback from participants to maximize
  the programs usefulness for providers.

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Questions / Discussion