Patient SafetyWhose Responsibility Is It Anyway?

Gwenn D. Randall, PhD, CRNA,ARNP CRNACAREERS/Mt. Pocono

October 2, 2021

DISCLAIMER

I HAVE NO DISCLOSURES

OBJECTIVES

• At the end of this presentation the participant will be able to:

1. Identify human factors in patient safety

2. Discuss task, team, and technology interaction

3. Illuminate importance of team communication

How Many Die From Medical Mistakes in U.S. Hospitals?

The Shocking Truth About M

edication Errors

P

HARMA & HEALTHCARE 9/03/2013

Wrong Patient Gets Kidney at USC Hospital

Patients rarely told about medication errors study Reuters | January 14, 2013

Medical Errors Harm Huge Number of Patients. What will it

take to make America’s hospitals safer?

US NEWS

Losing My Leg to a Medical Error

Vecuronium injected instead of Versed, 2017

Excessive amounts of Levophed administered,2014

Surgical 'Never Event' Leads to $25M Lawsuit Woman had stent put in wrong kidney at Vanderbilt University Medical Center

Why Do Docs Botch Surgeries? Researchers detail why 69 major errors occurred among 1.5M surgeries

Mother bleeds to death after childbirth; Palm Beach County OB-GYN loses his license

. What is Patient Safety?

Patient Safety

• “freedom from accidental or preventable injuries produced by medical care.” AHRQ Patient Safety Network

• “the prevention of harm to patients.” (IOM, 2000) – prevents errors – learns from the errors that do occur – a culture of safety that involves health care professionals, organizations, and patients

• “cornerstone of high-quality health care” (Aspden, 2004)

PATIENT SAFETY

• A new healthcare discipline that emphasizes the: • Reporting

• Analysis

• Prevention of medical errors

• Anesthesia Patient Safety Foundation (APSF) (1984) marked the first use of the term "patient safety."

• Anesthesia is leading medical specialty addressing issues of patient safety.

Institute of Medicine (IOM) considers patient safety “indistinguishable from the delivery of quality health care.

IOM, 1999

Institute of Medicine (IOM) Systems vs. Individuals

Health care in the United States is not as safe as it should be--and can be 1999

Fatalities Due to Medical Errors are Underreported

20161999

GLOBAL PREVENTABLE MEDICAL ERRORS

• Canada between 9,000 and 24,000 deaths/yr

• Germany has 17,000 deaths a year

• Bulgaria reports 7,000 deaths per year

• The Netherlands, 2,000 deaths per year

Anatomy of Medical Errors

• Limited memory capacity • Fatigue • Stress • Hunger • Illness • Language or cultural factors • Hazardous altitudes

FAA

HERE IS WHAT WE KNOW

CMS NOT reimbursing for “never ever” events

HERE IS WHAT WE DON’T KNOW

• Why only 14% of errors are being reported (Medicare) • Why aren’t hospitals doing a better job of tracking

preventable medical errors and infections?

• Why isn’t patient safety a high priority?

• Why the public doesn’t have access to critical information?

2003

“All men make mistakes, but a good man yields when he knows his course is wrong and repairs the evil. The only crime is pride.”

Sophocles, Antigone

FAILURE TO COMMUNICATE• Pervasive in health care system • Leading root cause of the sentinel events • Silo mentality • Barriers to communicate and collaborate

• Toxic Hierarchies • Disruptive behavior • Culture and ethnicity • Generational differences • Gender • Historical interprofessional and intraprofessional rivalries

Many errors occur due to fragility of human thinking

(Fortune, Davis, Hanson & Phillips, 2013)

SWISS CHEESE MODEL

• Accident causation model (Reason, 2000) • Holes represents individual

weaknesses (human factors)

• Holes represent the imperfections in individual safeguards or defenses.

• The system produces failures when a hole in each slice momentarily aligns, permitting "a trajectory of accident opportunity", so that a hazard passes through holes in all of the slices, leading to a failure

HUMAN FACTORS

• Ergonomics- how humans work in a specified system or environment

➢Human capabilities

➢Designs of systems to maximize safety, performance and ability to work together in harmony

• Non-technical skills (cognitive, social, personal)

➢ cognition & error ➢ situation awareness ➢ leadership & teamwork ➢ personality & behavior ➢ communication &

assertiveness ➢ decision making ➢ effects on human behavior:

tiredness & fatigue

HUMAN FACTORS • Acknowledges

– the universal nature of human fallibility – the inevitability of error

• Assumes that errors will occur

• Designs things in the workplace to try to minimize the likelihood of error or its consequences

HUMAN FACTORS

• Behaviors

• Systems

• Actions

• Individual

• Team of individuals

• Way individuals interact within the work environment.

Error, stress, and teamwork in medicine and aviation: cross sectional surveys

J Bryan Sexton, doctoral candidate,a Eric J Thomas, assistant professor,b and Robert L Helmreich, professoraBMJ. 2000 March18; 320(7237): 745–749. PMCID: PMC273

“We cannot change the human condition, but we can change the conditions under which humans

work.”

Reason J. BMJ 2000; 320:768-770

PARADIAGM SHIFT

Team of experts

Expert teams

Briefing Huddle Debriefing

12-18 inches apart, often at speeds up over 400 miles per hour!

John Foley, USN, Ret.

TRUST, TEAMWORK, PERFORMANCE

Application of a CRM Model to Medicine

1. Design of systems to absorb errors through redundancy, standardization, and checklists

2. Movement from placing blame to designing safe processes and procedures, i.e., applying a systems approach

3. Assurance of full immunity while implementing a nonpunitive approach

4. Debriefing of all events, including near misses, that have learning potential. Focus on the severity of the potential risk rather than on the severity of the event's final outcome is more conducive to establishing effective prevention programs 5. Institutionalization of a permanent program for risk identification, analysis, and dissemination of the lessons learned throughout the professional community

Crew Resource Management (CRM) UA1979

• Training procedures for use in environments where human error can have devastating effects (primarily for improving air safety)

• Encompasses a wide range of knowledge, skills, and attitudes - interpersonal communication - leadership - decision making in the cockpit - situational awareness - problem solving - TEAMWORK

STRUCTURED COMMUNICATION

• Crew Resource Management (CRM) • SBAR (Situation-Background-Assessment-Recommendation) • Culture of safety (I’m concerned) • TeamStepps • Guidelines • Protocols • Checklists

Sullenberger (US Airways #1549)

•

.

Spent the better part of two full days every six months at the controls of a behemoth, $10 million flight simulator while several lifetimes’ worth of midair disasters break loose around him

“Simulators are routinely used to re-create accidents to help figure out what went wrong and to develop procedures that can avert a rerun.”

"We can't forget that we are in the business of saving lives, not saving money."

“Pilots are being put in the cockpit without enough experience, and required to fly too much without adequate rest.”

Simulation in Education

• “Just in time” or “just in case” training • Learning occurs in a controlled environment • Integrated into normal educational offerings • Repetitive practice is mainstay • Skill acquisition • Immediate feedback • Reproducible, standardized • Outcomes are clearly defined

SIMULATION

Making Health Care Safer II :An Updated Critical Analysis of the Evidence for Patient Safety Practices Evidence Reports/Technology Assessments, No. 211 Rockville (MD): Agency for Healthcare Research and Quality (US); March 2013.Report No.: 13-E001-EF Chapter 38: Use of Simulation Exercises in Patient Safety Efforts

“SIMULATION IS MORE THAN A MANIKIN”

Seropian, 2004

Seropian, 2004

IOM

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population Alex B. Haynes, M.D., M.P.H., Thomas G. Weiser, M.D., M.P.H., William R. Berry, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., Abdel-Hadi S. Breizat, M.D., Ph.D., E. Patchen Dellinger, M.D., Teodoro Herbosa, M.D., Sudhir Joseph, M.S., Pascience L. Kibatala, M.D., Marie Carmela M. Lapitan, M.D., Alan F. Merry, M.B., Ch.B., F.A.N.Z.C.A., F.R.C.A., Krishna Moorthy, M.D., F.R.C.S., Richard K. Reznick, M.D., M.Ed., Bryce Taylor, M.D., and Atul A. Gawande, M.D., M.P.H. for the Safe Surgery Saves Lives Study Group

N Engl J Med 2009; 360:491-499 January 29, 2009DOI: 10.1056/NEJMsa0810119

Checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

Cognitive Aids

Safe Surgery Saves Lives The Second Global Patient Safety Challenge

BEYOND THE CHECKLIST

• Interprofessional Education • 2 or more professions learn from and about each other to improve

collaboration and quality of care

• Interprofessional Care • Art and science of working collaboratively for patient-centered

care

• Collaborative change leadership • Change leaders who lead staff in collaborative care initiatives for

quality and safety.

Debriefing an error

• Understand the multiple factors involved in failures • Avoid blaming • Was evidenced-based care practiced • Continuity of care for patients maintained • Stress the importance of self-care • Were actions ethical?

Five Human Performance Principles

1. Error is normal. Everyone makes mistakes.

2. Blame fixes nothing

3. Learning and improving are vital. Learning must be deliberate.

4. Context influences behavior

5. The response to failure matters

(Conklin, T, 2019)

T

E A

M

PATIENT SAFETY IS

EVERYBODY’S RESPONSIBILITY

References• AHRQ PSNet Patient Safety Network. Patient safety. [Accessed October 20, 2007]. http://psnet.ahrq.gov/glossary.aspx#P

• Aspden P, Corrigan J, Wolcott J, et al., editors. Patient safety: achieving a new standard for care. Washington, DC: National Academies Press; 2004.

• Commonwealth Fund International Survey: Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries (2005)

• Human Factors and Ergonomics Society (HFES) www.hfes.org

• Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000. • ournal of Patient Safety: • James, J. (2013) New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9(3);

122-128. • Michelle O’Daniel, Alan H. Rosenstein Chapter 33. Professional Communication and Team Collaboration http://www.ahrq.gov/

professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/ODanielM_TWC.pdf • National Patient Safety Foundation http://www.npsf.org/for-patients-consumers/patients-and-consumers-key-facts-about-patient-safety/ • Reason, James (2000-03-18). "Human error: models and management". British Medical Journal 320 (7237): 768–770. doi:10.1136/

bmj.320.7237.768. PMC 1117770.PMID 10720363.

• Winta T. Mehtsun, M.D., M.P.H.; Andrew M. Ibrahim, M.D.; Marie Diener-West, Ph.D.; and Peter J. Pronovost, M.D., Ph.D JOHNS HOPKINS MALPRACTICE STUDY: SURGICAL ‘NEVER EVENTS’ OCCUR AT LEAST 4,000 TIMES PER YEAR

• World Health Organization (2009). Human Factors in Patient Safety: Review of Topics and Tools. WHO/IER/PSP/2009.05 • (http://www.who.int/patientsafety/en/index.html

• Tomlin,Janice (producer): The Deep Sleep: 6,000 will die or suffer brain damage, WLS-TV Chicago, 20/20. April 22, 1982

•

PATIENT SAFETY

• 1989- Australian Patient Safety Foundation • 2000- UK The Department of Health Expert Group • 2004- The Canadian Adverse Events Study • 2001- New Zealand • 2001- Denmark • 2004- World Alliance for Patient Safety

General Surgery Residency Inadequately Prepares Trainees for Fellowship: Results of a Survey of Fellowship Program Directors Mattar, Samer G. MD*; Alseidi, Adnan A. MD, FACS†; Jones, Daniel B. MD, FACS

Annals of Surgery: September 2013 - Volume 258 - Issue 3 - p 440–449

Results: The respondent program directors felt that new fellows:21% - arrived unprepared for the operating room38% - demonstrated lack of patient ownership30% - could not independently perform a laparoscopic cholecystectomy66% - were deemed unable to operate for 30 unsupervised minutes of a major procedure.With regard to laparoscopic skills:30% could not atraumatically manipulate tissue26% could not recognize anatomical planes56% could not suture

TEAM STEPPS APPROACH