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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. Objectives. 1. Describe common risks to the safety of dialysis patients. 2. Examine ways to use quality - PowerPoint PPT Presentation
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Meeting the Critical
Challenge to Ensure Patient
Safety & Quality
Meeting the Critical
Challenge to Ensure Patient
Safety & Quality
Glenda M. Payne, MS, RN, CNN
Director of Clinical Services
Nephrology Clinical Solutions 1
ObjectivesObjectives
1. Describe common risks to the safety of dialysis patients
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
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
3. Discuss initial steps to implement a facility based program to improve quality and safety
2
Risks to Patient Safety: Medical Errors
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)
3
Cost of Medical ErrorsCost 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.
4
Most Common Causes of Patient Injuries
Most Common Causes of Patient Injuries
• Wrong site surgery
• Medication errors
• Healthcare acquired infections
• Falls
• Readmissions
• Diagnostic error
National Patient Safety Foundation (NPSF)
5
Most Common Patient Injuries: Potential in ESRD
Most Common Patient Injuries: Potential in ESRD
• Wrong site surgery
• Medication errors
• Healthcare acquired infections
• Falls
• Readmissions
• Diagnostic error
National Patient Safety Foundation (NPSF)
6
Preventing Medication Errors in ESRD 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 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
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 FallsReducing 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 ReadmissionsReduce 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 Diagnostic Errors in Dialysis
• Think fluid management…
12
How Do You Make Your Facility Safer? How Do You Make Your Facility Safer?
• 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 InjuryOther Ways to Prevent Patient Injury
Build in Safety:
• Product ordering/ receipt of supplies
• Systems design
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“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
Human Factors DesignHuman 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
HOW TO BUILD A CULTURE OF SAFETY IN YOUR FACILITY
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Quality Improvement Quality Improvement
ActPlan
Do
Study
Patient SafetyPatient Safety
Constant Process
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Involve the Whole Team In QAPIInvolve 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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19
Too Many Of Us Never Get Above Data…
Effective QAPIEffective QAPI
• 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 AnalysisRoot 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 WhoFocus On The Why & How, Not The Who
Root Cause
Why WhyWhy Why
How How How
22
Prevention Not Punishment 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 PeopleTarget 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
24
Patient Exposure to ChlorineSwiss Cheese Model
Pat
ient
s H
arm
ed
Staf
f tra
inin
gC
hang
e in
test
ing
met
hod F
loat
Cha
rge
Nur
se
Pre
ssur
e to
get
pa
tient
s on
Labe
ling
of
test
ing
site
s
steps
latent errors
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Can Never Eliminate All ErrorsCan 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 Safety26
Patient Safety ProgramPatient Safety Program
•Routinely monitor PE•Educate staff •Implement med error reduction plan•Implement IC plan•Educate patients
•Routinely monitor PE•Educate staff •Implement med error reduction plan•Implement IC plan•Educate patients
•Develop facility PE monitoring tool •Develop staff ed•Develop med error reduction plan •Develop IC guidance•Develop patient education
•Develop facility PE monitoring tool •Develop staff ed•Develop med error reduction plan •Develop IC guidance•Develop patient education
•Inspect facility for hazards•Evaluate staff competency•Determine med error rate•Determine infection rate•Evaluate patient engagement
•Inspect facility for hazards•Evaluate staff competency•Determine med error rate•Determine infection rate•Evaluate patient engagement
AssessAssess PlanPlan ImplementImplement
Repeat
27
But I’m Just One Person…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!
28
Assumptions and PresumptionsAssumptions 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
29
Communication: The Hardest ThingCommunication: 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 Fly30
Learn To CUSLearn To CUS
• Concerned/ Uncomfortable/ SSafety
• “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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