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Understanding Patient Safety

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Understanding Patient Safety Presented by Dr. Redouane Bouali Canadian Patient Safety Institute (CPSI) June 10th, 2010 * * Discuss role of leadership in culture ... – PowerPoint PPT presentation

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Title: Understanding Patient Safety


1
Understanding Patient Safety
  • Presented by Dr. Redouane Bouali
  • Canadian Patient Safety Institute (CPSI)
  • June 10th, 2010

2
Mission
  • To provide national leadership in building and
    advancing a safer Canadian health system

Vision
  • We envision a Canadian health system where
  • Patients, providers, governments and others work
    together to build and advance a safer health
    system
  • Providers take pride in their ability to deliver
    the safest and highest quality of care possible
    and
  • Every Canadian in need of healthcare can be
    confident that the care they receive is the
    safest in the world.

3
A Sad Story
  • Noisy place!!
  • KCI bed Rep
  • 65 years patient, in ICU being dialyzed
  • Two nurses signing over
  • Patient experienced an arythmia
  • No body noticed the ECG strip....
  • No body could hear the alarm Bell
  • He interrupted the nurses sign off and asked if
    he can bring his bed.
  • The nurses suddenly realized that the patient was
    in cardiac arrest.....
  • It was too Late!!!

4
Nosocomial infection outbreak
  • Burn Unit
  • Experienced outbreak
  • MRSA and VRE
  • Serious concerns....
  • Security control at the front door
  • Hand Washing Mandatory!!!!
  • Line infection!!!!
  • A BIG CONCERN!!!

5
Results Catheter infections
6
A very poor communication
  • 24 years old man medical student
  • Visited ER for abdominal pain
  • Discharged after 36 hours with diagnosis of
    Gastritis.
  • Patient went again to the ER for the same problem
  • Patient insisted to go home because he had
    important test to do at the University
  • Patient went to his hometown... Operated the same
    night for Appendicitis (After 10 days!!!)

7
Poor communication
  • Patient two days post op when was authorized to
    go home , while walking in the parking
    crashed!!!!
  • Died after 2 hours of CPR
  • Parents devastated asked several times for an
    explanation (head of Surgery, head of Emergency,
    in the two hospitals ....)
  • Finally after few months they went to the
    Media,,,,,,

8
Overview
  • Introduction to Patient Safety
  • Systems vs. Person Approach
  • The Safety Competencies
  • The Role of the Clinician, Team and Patient
  • Strategies to Improve Patient Safety
  • Conclusion

9
Background
  • The Quality in Australian Health Care Study
    (1995)
  • The U.S. Institute of Medicine published the
    report To Err is Human (1999)
  • The British Report, An Organization with a
    Memory from the National Health Service (2000)
  • National Steering Committee on Patient Safetys
    Building a Safer System (2002)
  • The Canadian Adverse Events Study (2004)

10
Canadian Adverse Events Study
Adverse Event (AE) is defined as an
unintended injury or complication that results in
disability at the time of discharge, death or
prolonged hospital stay and that is caused by
health care management rather than by the
patients underlying disease process. Baker
GR, Norton PG, Flintoft V, Blais R, Brown A, Cox
J et al. (2004). The Canadian Adverse Events
Study The incidence of adverse events among
hospital patients in Canada. CMAJ, 170(11),
1678-1686.

11
Canadian Adverse Events Study
  • Findings
  • 3,745 charts reviewed
  • 7.5 of hospital admissions involve adverse
    event 37 of adverse events preventable
  • Extrapolation
  • Of 2.5 million hospital admissions in Canada in
    2000
  • 185,000 experienced 1 or more adverse events
  • 70,000 of the 185,000 were determined to be
    preventable
  • between 9,000 and 24,000 deaths due to adverse
    events could have been prevented

12
Canadian Adverse Events Study
1,100,000
Extra hospital days associated with adverse events
Deaths among patients with preventable adverse
events
13
What We Know
  • Canadian Institute for Health Information (2004)
  • One in ten adults contract infection in hospital.
  • One in ten patients receive wrong medication or
    wrong dose.
  • More deaths after experiencing adverse events in
    hospital than deaths from breast cancer, motor
    vehicle and HIV combined.

14
Epidemiology of Harm
Study Date of admission Number of hospital admissions Adverse event rate ( admissions)
California Insurance Study 1974 20864 4.65
Harvard Medical Practice Study 1984 30195 3.7
Utah-Colorado 1992 14052 2.9
Australian 1992 14179 16.6
United Kingdom 1999 1014 10.8
Denmark 1998 1097 9.0
New Zealand 1998 6579 11.2
France 2002 778 14.5
Canada 2000 3745 7.5
World Health Organization. (2004). World Alliance
for Patient Safety Forward programme 2005.
Geneva, Switzerland World Health Organization.
Retrieved from http//www.who.int/patientsafety/en
/brochure_final.pdf
15
(No Transcript)
16
Definitions
  • Patient Safety - The reduction and mitigation of
    unsafe acts within the healthcare system through
    the use of best practices shown to lead optimal
    patient outcomes.
  • (Canadian Patient Safety Dictionary, 2003)
  • Adverse Events - Unintended injuries or
    complications that are caused by health care
    management, rather than the patients underlying
    disease, and that lead to death, disability at
    the time of discharge, or prolonged hospital
    stays.
  • (Baker et al., 2004)
  • Harm - An outcome that negatively affects a
    patients health and/or quality of life.
  • (Canadian Disclosure Guidelines, 2008)

17
Adverse Events
  • Delayed or missed diagnoses
  • Medication errors
  • Wrong side surgery
  • Wrong patient surgery
  • Equipment failure
  • Patient identity
  • Transfusion errors
  • Mislabeled specimen
  • Patient/resident falls
  • Time delay errors
  • Laboratory errors
  • Radiology errors
  • Procedural error
  • Lost, delayed, or failures to follow up reports
  • Retention of foreign object following surgery
  • Contamination of drugs, equipment
  • Intravascular air embolism
  • Failure to treat neonatal hyperbilirubinemia
  • Stage lll or lV pressure ulcers acquired after
    admission
  • Wrong gas delivery
  • Deaths associated with restraints or bedrails
  • Sexual or physical assault

18
Adverse Events vs. Critical Incidents
  • Not all negative patient outcomes are adverse
    events
  • Not all adverse events
  • are critical incidents

Negative Outcomes
Adverse Events
Critical incidents are the most serious
preventable adverse events.
Critical Incidents

19
What Patient Safety Is and Is Not
  • It is NOT what most of us were thinking about 10
    years ago
  • It is NOT what we have always done
  • It is the most significant change in the
    healthcare system in over a century
  • It is a new applied science
  • It has forever changed the face of modern
    healthcare

20
Risky Activities (Adapted by Dr. Philip Hebert)
15,000 deaths/yr
Dangerous (gt1/1000)
Regulated
Ultra-safe (lt1/100K)
100,000
Hospitalization
10,000
Driving
Total Lives Lost per year
1,000
Commercial airlines
Firearms
100
10
Scuba diving
1
10
100
1,000
10,000
100,000
1,000,000
10,000,000
Number of encounters for each fatality
21
The Challenge
In health systems, the challenge is to change the
environment from one of crisis and blame to that
of learning and improvement.
Emory Center on Health Outcomes
Quality Partnership for Health Accountability,
July 2004
22
Determinants of Adverse Events
  • The System
  • The People

23
Most problems are found in processes, not
in people. 
24
A System Perspective
  • A system can be described as
  • A grouping of components, such as resources and
    organization (structure) that act together
    (process), to achieve a particular result
    (outcome).
  • (Canadian Patient Safety Dictionary, 2003)
  • Clearly certain structure is needed and equally
    clearly, there is no way to change outcome except
    through changing process, since outcome tells
    on process.
  • Slee VN, Slee DA Schmidt HJ (1996).
  • Slees Health Care Terms, 3rd edition.
  • St. Paul, MN Tringa Press.


25
Sources of System Error
  • Overall culture
  • Education / training / experience
  • System design / engineering
  • Resource availability
  • Demand / volume
  • Throughput impedance
  • Shift-work schedules

26
The Systems Approach

Reason, J., (2000), BMJ (320), 768.
27
The Systems Approach
though we cannot change the human condition,
we can change the conditions under which humans
work. Reason, J. (2000). Human error Models
and management. BMJ, 320(7237), 768-770.


28
The Person Approach
  • Historically focused on individual performance
    and not system issues
  • Front line staff often not involved in the review
    of an adverse event
  • Partial or incomplete solutions that do not
    fully resolve the underlying cause and leave the
    organization vulnerable to reoccurrence of the
    event
  • Fear of reprisals drives important information
    underground


29
What about professional accountability?
  • Does a system approach mean that individual
    practitioners are not accountable for their
    actions?


30
Sources of Personal Error
  • Skill-based errors
  • Rule-based errors
  • Knowledge-based error

31
The Person Approach
  • Incompetent people are 1 of the problem. The
    other 99 are good people trying to do a good job
    who make very simple mistakes and it's the
    processes that set them up to make these
    mistakes.
  • Dr. Lucian Leape, Harvard School of Public Health

32
Person vs. Systems Approach
  • Systems
  • Begin with the premise that anything can and will
    go wrong
  • Dont expect humans to perform perfectly
  • Design systems accordingly in a proactive way
  • Collective preoccupation with possibility of
    failure
  • Person
  • Errors are the result of human failures
  • Humans generally perform flawlessly
  • Perfect performance is the expectation
  • Use retraining and punishment to root out bad
    apples


33
(No Transcript)
34
The Safety Competencies
  • Domain 1
  • Contributing to a culture
  • of patient safety
  • Definition A commitment to applying core patient
    safety knowledge, skills and values to everyday
    work

34
35
Shared Accountability-Just Culture-
  • it is about creating a reporting environment
    where staff can raise their hand when they have
    seen a risk or made a mistake..where risks are
    openly discussed between managers and staff.
  • while we as humans are fallible, we do
    generally have control of our behavioural
    choices.
  • good system design and good behavioural choices
    of staff together produce good results. It has
    to be both.
  • Marx D, Comden SC, Sexhus Z (2005). Our
    inaugural issue in recognition of
  • a growing community.The Just Culture Community
    News and Views, 1(1).

35
36
Safety Culture
  • Excessive blame prevents recognition of error,
    impedes learning and effective action to improve
    safety.

37
Safety Culture
  • Join us in converting a culture of blame that
    hides information about risk and error into a
    culture of safety that flushes out information to
    prevent patient injuries.
  • (Leape et al, 1998)
  • A somewhat lethal cocktail of impatience,
    scientific ignorance and naïve optimism may have
    dangerously inflated our expectations of safety
    culture.
  • (Cox Flin, 1998)

38
Culture as Awareness
  • Awareness of error and harm
  • Willingness to discuss openly
  • Open and fair culture
  • Open disclosure
  • Essential foundations

39
Culture
  • Teamwork
  • All focused on accomplishment of mutual goals
  • Aim for high-quality performance
  • When something goes wrong
  • The focus is on what happened, rather than who
    did it
  • Atmosphere of how do we find the issues /
    weaknesses and solve them

40
The Safety Competencies
  • Domain 2
  • Work in teams for patient safety
  • Definition Working within interprofessional
    teams to optimize patient safety

40
41
Teamwork in Healthcare
  • Healthcare must establish team training programs
    for personnel in critical care areas . . . using
    proven methods such as the crew resource
    management training techniques employed in
    aviation
  • (Kohn et. al, 2000)

42
The Safety Competencies
  • Domain 3
  • Communicate effectively
  • for patient safety
  • Definition Promoting patient safety through
    effective health care communication

42
43
Communication / Team WorkWhy is it critical?
  • Nearly all instances of unexpected adverse events
    involve communication failures
  • Joint Commission sentinel event data -more than
    2400 serious case analysis revealed communication
    failures were root cause in over 70

43
44
The Safety Competencies
  • Domain 4
  • Manage safety risks
  • Definition Anticipating, recognizing and
    managing situations that place patients at risk

44
45
Clinicians Create Safety
  • Err on the side of safety speak up and ask
    questions. Be safe first and brave afterwards.
  • Be obsessive about hand washing. Be very aware of
    why we need to do this and less irritated about
    the time it takes.
  • Have enough humility to recognize when you are
    out of your depth. Be willing to ask for help and
    receive help.
  • Assess the situation and Be prepared to Complete
    the task.

46
Teams Create Safety
  • Make it clear what protocol or plan is being
    used.
  • Messages and communications are acknowledged and
    repeated by those who receive them.
  • Team members are aware of others actions and are
    ready to step in to support and assist.
  • Team members support and monitor each other.
  • Speak up when a patient is at risk.

47
Patients Create Safety
  • Speak up if you have questions of concerns, and
    if you dont understand, ask again. Its your
    body and your health, you have a right to know.
  • Pay attention to the care youre receiving. Make
    sure youre getting the right treatments and
    medications. Dont assume anything.
  • Notice whether your caregivers have washed their
    hands. Dont be afraid to remind them to do this.

48
The Safety Competencies
  • Domain 5
  • Optimize human and
  • environmental factors
  • Definition Managing the relationship between
    individual and environmental characteristics to
    optimize patient safety

48
49
Strategies to ImprovePatient Safety
  • Hand hygiene
  • Human factors engineering
  • Safer Healthcare Now interventions
  • Improved care for Acute Myocardial Infarction
  • Prevention of central-line associated bloodstream
    infection
  • Medication reconciliation (Acute care/Long-term
    care)
  • Rapid response teams
  • Prevention of surgical site infections
  • Prevention of ventilator-associated pneumonia
  • Antibiotic resistant organisms (MRSA)
  • National collaborative on falls in long-term care
  • Venous thromboembolism
  • Governance for safety and quality

49
50
10 Patient Safety Tips-Healthcare Professionals-
  • Communication
  • Introduce yourself to your patients and let them
    know that you invite them to bring any concerns
    to your attention
  • Dont allow patient and family concerns to go
    unresolved
  • Listen! Listen! Listen!
  • Maintain Situational Awareness (be alert, follow
    your intuition)
  • Participate in the implementation of a common
    communication tool (e.g. SBAR)

51
10 Patient Safety Tips-Healthcare Professionals-
  • Behaviours / Competencies
  • Use recommended patient safety practices
  • Understand where and how to report adverse
    events
  • Participate in the testing of new devices
  • Be aware of your own limitations (e.g. fatigue,
    biases)
  • Seek out information about patient safety and
    incorporate it into your practice

52
The Safety Competencies
  • Domain 6
  • Recognize, respond to and disclose adverse events
  • Definition Recognizing the occurrence of an
    adverse event or close call and responding
    effectively to mitigate harm to the patient,
    ensure disclosure, and prevent recurrence

52
53
Understanding Harm
  • Definitions

Canadian Disclosure Guidelines CPSI
54
54
55
Safety is in Your Hands
  • We will NOT solve the problems of safety
  • by assuming they are just the risks inherent in
    healthcare or by blaming someone.
  • Neither will solve the issues.
  • ONLY THROUGH OUR SYSTEMATIC EFFORTS CAN WE
    IMPROVE SAFETY FOR THE PATIENTS, CLIENTS, AND
    RESIDENTS THAT WE CARE FOR

56
CPSI - Strategic Direction
  • Click to ad text

57
CPSI - Areas of Focus
  • --------------------------------------------------
    --------

Education Executive Patient Safety
Series Simulation Halifax Conferences Canadian
Patient Safety Officer Course Patient Safety
Competencies
Research Mental health Home care Long Term
Care Building Capacity through Research
Interventions Programs World Health
Organization High 5s Patients for Patient
Safety Human Factors Culture of Patient
Safety Canadas Hand Hygiene Campaign Safer
Healthcare Now!
Tools Resources Root Cause Analysis Electronic
Health Record Canadian Disclosure
Guidelines Canadian Adverse Event Reporting and
Learning System Safe Surgery Checklist
58
What more could CPSI bring?
  • Contribution to physician engagement
  • Safe Surgery Checklist done!
  • Safe Prescribing Checklist- potential?
  • Safety/Pharma clips potential?

59
Système et processus intégrés

Saisie de données manuelles est réglée par des
gestes normaux du personnel médical
hôpital
Bureau/unité


recherche
ADT
Futur fin 2010
LABS
maison

dossier patient
Pharm
envois HL7
VPN
Réseau interne
Externe à lhôpital
60
personnalisables
Ventilé, Cathéters, Microbiologie, Labos
Évolution des 10 dernières meures
Seuil critique Avertissement
Retour à une norme acceptable Norme
acceptable
Valeurs et alertes personnalisées par
lutilisateur changements/mise à jour
automatiques
61
Summary
  • Patient safety is everyones responsibility
  • Understanding the problem is the first step
    towards improvement
  • When errors are viewed as an opportunity for
    improvement rather than punishment, patients will
    benefit

Vincent et al, (1998). BMJ, 316, 1154-7.
62
Take Home Message
  • there are some patients we cannot help, there
    are none we cannot harm...

Arthur Bloomfield, M.D.
Quality of Healthcare in America Project
2003 -----Dr. Ken Stahl
63
  • Thank You

63
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