Do No Harm: Culture, Technology, Teamwork and Design Change

1
Do No Harm Culture, Technology, Teamwork and
Design Change

• Nancy G. Pratt RN, MSN,
• SVP, Clinical Effectiveness
• Sharp HealthCare
• February 5, 2007

2
Sharps Strategic Plan for Patient Safety
Develop a Culture of Safety Use Technology to
Improve Safety Address Human Factors Teamwork
and Communication Redesign the Processes
Culture
Human Factors
Reduce Harm by 50 over 5 years
Design
Technology
3
Strategic Priorities Patient Safety

• Implement a Culture of Safety
• Anonymous reporting
• Collaboration San Diego Patient Safety
  Consortium
• Adverse Events Program
• Teamwork and Communication
• Team Resource Management
• Standard Work Processes
• Use Technology to Improve Safety
• Bar Coding
• Electronic Safety Triggers
• Electronic variance reporting
• Smart Pumps IV, PCA, Syringe
• Redesign for Safety
• Human Factors Engineering
• Design for Six Sigma
• Product, supply, process review
• JCAHO National Patient Safety Goals

4
Six Sigma Projects Patient Safety
Six Sigma Projects Status
Medication Safety Done
Pharmacy Order Cycle Time Done
SMH Discharge Project Underway
SCV Discharge to SNF Underway
SGH Discharge Project Underway
SHC Cerner CPOE Paper Lite Started
ROMACC (Reconciliation of Medications) Started
5
Alternate Actual Process
Physician gives order
RN cant get med out of Pyxis
RN writes order faxes to Pharmacy
Fax doesnt go through! Pharmacist not
available Drug not available
RN faxes calls pharmacy again! Onset of
Complaints!
RN Calls pharmacy, faxes order again!! Fills out
standard pharmacy complaint QVR!
Pharmacy Tech delivers med someplace in SICU
Pharmacy informs RN med has been there for 2 hours
6
Pharmacy Order Cycle Time
Pharmacy Staffing Not Matched to Medication Order
Volume
Medication Orders
Pharmacy Staffing
Time of Day
7
Pharmacy Order Cycle Time
After Initial Improves
Baseline
After Pharmacy IT System Changed
After Fax Server Installed
8
Pharmacy Order Cycle Time
9
Med Admin Flow Map(Ideal)Average time 7 mins
Medication Safety Project Decrease Interruptions
RN preps med
RN Prompted to give med
RN identifies patient
RN interprets MAR (5Rs)
RN explains med to pt
RN performs preadministration assessment / checks
allergies
RN prepares to admin med (final 5Rs)
RN washes hands
RN evals effects of med
RN gives med
RN procures med/IV supplies (5Rs)
RN documents med
RN washes hands
10
Med Admin Flow Map(More real)Average time 20
mins
RN preps med
RN Prompted to give med
Wait in line
RN identifies patient
RN interprets MAR (5Rs)
Phone call
Phone call
Order is questionable
RN explains med to pt
RN performs preadministration assessment / checks
allergies
Need to clarify
Unexpected nsg task
RN prepares to admin med (final 5Rs)
Call MD Wait Get clarification
RN washes hands
Locate Missing supply
RN evals effects of med
RN gives med
Unexpected nsg task
Phone call
RN procures med/IV supplies (5Rs)
Cant find med look in 4 places call pharm
RN documents med
RN washes hands
11
CR

• Waited in line to get meds _at_ 900
• One med grayed out not here, one gray ed at
  in refrigerator
• Search refrigerator
• Went to P 1, found 1 med MVI still missing,
  tapped drawer to get cubie to open
• Two meds left to find may be in room. Crushed
  meds in paper cups
• Piston syringe in room No date went to supply
  room to get another
• Found MVI but NO med cups - ? Refrigerator MVI
• Searched room for fiber or med cup on bedside
  table no way to administer
• Back to med room
• Back to room
• Mixed meds in cup in admin DONE 0920
• Medication Delivery Total Time 13 minutes

12
What Does the Literature Tell Us? Top High Risk
Situations Causing Sentinel Events

• Distractions before or during administration of
  meds or treatment
• High alert drugs used without double-checks
• Multi-tasking
• Care provided under a human-error-prone situation
  (dark, noisy, shift change) without appropriate
  compensatory actions

Reason, JT. Understanding adverse events human
factors. In Vincent CA (ed) Clinical Risk
Management. London BMJ Pub 1995
13
Medication Safety Action Plan

• Create a standard environment for medication room
  design and processes
• 5S Principles
• - Sort
• - Shine
• - Simplify
• - Standardize
• - Sustain
• Minimize interruptions and distractions during
  medication administration
• Respect med admin as a critical activity
• Divert and discourage unnecessary calls
• Encourage all disciplines to limit interruptions
  Create Scripting examples for nurses
• Evaluate workload demands during high volume med
  admin times

14
Medication Safety Action Plan

• Develop a standard guideline for
• medication preparation and administration
• Avoid conversations in med room
• Discourage interruptions/distractions
• Verify using 7 Rights
• Prepare and administer to 1 pt at a time
• Independent double check insulin, heparin,
  warfarin
• Use MAR or Pyxis label to verify 7 Rs
• Document

15
24 06 09 12 17 21

16
Number of Unnecessary Interruptions During Med
Pass Pre and Post
p0.000
No statistical difference in number or route of
meds given
17
SGH 5E Pilot Med Pass TimePre and Post
p0.037
No statistical difference in number or route of
meds given
18
Emergency Department RME

• ED patients expect quick service and to be seen
  by an ED doctor, regardless of diagnosis
• 40 of ED pts are non-emergent
• Rapid Medical Exam (RME) designed to promptly and
  appropriately treat release
• Issues long waits, space, multiple entry points,
  flow, communication

19
ED Waits Decrease Satisfaction
20
Growth of ED Visits

• 1992 12 beds 16,640 visits. 2006 22 bed
  45,456 visits.
• 173 increase in visits since current ED was
  opened in 1992.
• 83 increase in beds over same period.

21
ED Outpatient Overall Satisfaction(scale 0-100)
22
Bottlenecks in the ED
PHLEBOTOMY
TRIAGE
LOBBY
RME
Lack of open ED beds creates bottlenecks. Many
patients wait in front lobby area.
23
Key Process Steps
24
RME Project Goals

1. Take vitals of all ESI level 2-3 patients in
   lobby every 90 min 90 of time (baseline 0)
2. Arrival noticed quickly satisfaction 85th
   percentile (baseline 18 Dec-06)
3. Establish RME triage standard to set stage for
   RME cycle time project

25
ED RME Outcomes

• Goal Vitals on all ESI level 2-3 patients in
  lobby every 90 min 90 of time (baseline 0).
  Improvements
• Guard providing safe environment
• LVN assigned to check vitals
• Designed EmStat report to monitor lobby patients

26
ED RME Outcomes
Goal 80th tile
27
Reconciliation of medications across the
continuum of care
RoMACC at Grossmont Hospital
Project Description / Vision Implement a Lean
RoMACC process that demonstrates value, not just
in terms of patient safety but in efficiency for
practitioners.
Start Date September 2006 Go Live December
5th End Date March 2007 Participants
Champion/Green Belt Julie McCoy Jackie
Parson Black Belt Kurt Hanft
Sponsor Michele Tarbet MD Partner/ Process
Owner Dr. Margaret Elizondo
Next Sustain and Improve!
28
Reconciliation of medications across the
continuum of care
RoMACC Measurement Method
Discharge
Physician writes the Discharge Orders and
Addresses the Discharge Reconciliation.
Unit clerk verifies the reconciliation has been
addressed and enters a discharge order
Process Measure
29
Reconciliation of medications across the
continuum of care
RoMACC and Discharge Measurement

• RoMACC Complete
• Carecast Discharge Order Entry Compliance
• Number Of Discharges
• Time to Discharge a Patient
• Average Time of Day a Patient Leaves.

Combined projects
30
Reconciliation of medications across the
continuum of care
RoMACC at Grossmont Hospital
75 System Goal
Continuous Improvement Above System Goal of 75
31
Examples of Patient Safety Improvements
Use Technology to Improve Safety Bar
Coding Electronic Safety Triggers Electronic
variance reporting Smart Pumps IV, PCA, Syringe
Innovation with our partners Cerner
Bar Code Implementation (Roche) Real Time
Event Triggers On Watch (Clinicomp) Electronic
Quality Variance Reporting (Peminic) Wireless
Smart Pumps CQI data (Cardinal) Standardization
of IV infusion concentrations (SDPSC) Enteral
Tubing connections (Viasys, FDA, AHA)
32
System Reprogramming Safety Achieved Quarter 1
2006
n145
33
Alaris Guardrails
34
(No Transcript)
35

• Tubing Misconnections

36
Patient Safety Strategy

• Redesign for Safety
• Human Factors Engineering
• Design for Six Sigma
• Product, supply, process review
• JCAHO National Patient Safety Goals

37
Patient Safety Actions

• Products
• Insulin Syringe
• Dopamine Drip Bottle versus Bag
• Enteral Feeding Bag versus Bottle
• Heparin Flush versus Therapeutic infusion
• Anesthesia Tray for Epidural
• Cat Scan Contrast Injectors
• IV PICC Line Cap Leaking (CLC 2000)
• Insulin and Heparin Infusions standardized
• Endotracheal Tube with Sub-glotic suction

38
San Diegos Health Care Leader
Malcolm Baldrige National Site Visit, 2006
Gold Eureka Award, 2006 Silver Eureka Award,
2005 Bronze Eureka Award, 2004