The Science of Improving Patient Safety
Sean Berenholtz, MD, MHS, FCCM
September 4, 2012
Armstrong Institute for Patient Safety and Quality
Conference Number(s):800-779-9891
Participant Code:4757941
On Boarding Call Schedule
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Program Introduction
Building Your CUSP Team
Science of Safety –September 4, 2012 @2:00pm
Building Your CUSP Team-September 11, 2012 @2:00pm
VAP Evidence- September 18,2012 @ 2:00pm
Daily Goal Review -September 25, 2012 @ 2:00pm
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Learning Objectives
• Explain how every system is designed to
achieve the results it gets
• Identify and describe the basic principles of
safe design
• Apply the principles of safe design to
technical as well as teamwork
• Identify how teams make wise decisions
when there is diverse and independent
input
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Targeted Muscle Re-Innervation
(courtesy of Dr. Albert Chi)
1. Nerve Transfers
2. Motor Imagery (3 mo)
3. TMR Prosthetic (6 mo)
4. Sensory functions
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http://home.earthlink.net/~radiologist/tf/050800.htm
The Problem is Large
• In U.S. Healthcare system
– 7% of patients suffer a medication error
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– On average, every patient admitted to an ICU suffers an adverse event 2,3
– 44,000- 98,000 people die each year as the result of medical errors
– Nearly 100,000 deaths from healthcare-associated infections
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– Estimated 30,000 to 62,000 deaths from CLABSIs 6
– Cost of HAIs is $28-33 billion 7
• 8 countries report similar findings to the U.S.
1.
Bates DW, Cullen DJ, Laird N, et al., JAMA,1995
2.
Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.
L, Stocking C, Krizek T, et al., Lancet, 1997.
4. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.
5. Klevens M, Edwards J, Richards C, et al., PHR, 2007
6. Ending Health Care-Associated Infections, AHRQ, 2009.
3. Andrews
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How Can These Errors Happen?
• Every system is perfectly designed to
achieve the results that it gets
– majority of errors don’t belong to individual
doctors or nurses
• People are fallible
• Need to view the delivery of healthcare as a
science
• Need systems that catch mistakes before
they reach the patient
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Rather than being the main instigators
of an accident, operators tend to
be the inheritors of system
defects….. Their part is that of
adding the final garnish to a lethal
brew that has been long in the
cooking.”
James Reason, Human Error, 1990
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System Factors Impact Safety
Case Example
• 65 yo M s/p lung resection for cancer
• Admit to ICU; discharged to floor on post-op
day (POD) 1
• POD 3 develops hypoxia
• Admitted to ICU, intubated
• CXR shows extensive left lung collapse
• Decision to perform broncoscopy
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System Failure Leading to Error
Did not verify
equipment availability
Fatigue
Bronch cart
not stocked
Patient suffers
Communication between
resident and nurse
Hypoxic arrest
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Science of Safety
• Understand principles of safe design
– Standardize, create checklists, learn when
things go wrong
• Recognize these principles apply to
technical and team work
• Teams make wise decisions when there is
diverse and independent input
Health Services Research, 2006; Circulation. 2009;119:330-337
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Eliminate Steps
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Create Independent Checks
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Healthcare-Associated Infections (HAI):
A Preventable Epidemic
• Focus on 4 HAIs:
– VAP, CLABSI, surgical site infections and catheter
associated urinary tract infections
• $5 billion per year excess costs
• 1.7 million patients per year
– 1 out of 20 patients
• 98,000 deaths per year
– As many deaths as breast cancer and HIV/AIDS
– 6th leading cause of preventable deaths
http://oversight.house.gov/story.asp?id=1865
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VAP Prevention Guidelines
• CDC Guidelines
• MMWR Recomm Rep. 2004;53:1-36
• American Thoracic Society/Infectious Diseases
Society of America
• AJRCCM 2005;171(4):388-416.
• Canadian VAP Prevention Guidelines
• J Crit Care 2008;23(1):138-147.
• Society for Healthcare Epid of
America/Infectious Diseases Society of America
• ICHE 2008;29:S31-S40.
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Improving Care for Ventilated
Patients
• Semirecumbant positioning
• Peptic ulcer disease and DVT prophylaxis
• Appropriate sedation
• Daily assessment of readiness to extubate
• Minimize contamination of equipment
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Improving Care for Ventilated
Patients
• Educate staff
• Decrease complexity / create redundancy:
– Daily goals checklist
• Other independent redundancies
– Nursing and families
– Are patients receiving the prevention they
should?
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Sample Daily
Goals
• What needs to be
done for the patient
to be discharged?
• What is the patients
greatest safety risk?
• What can we do to
reduce the risk?
• Can any tubes,
lines, or drains be
removed?
J Crit Care. 2003;18(2):71-75
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Michigan Keystone ICU –
Results
• 124 of 127 ICUs submitted VAP data
– 12 ICUs started after funding ended
• 112 ICUs, 72 hospitals included in analysis
• 3228 ICU months and 550,800 vent days
• 10% quarters without complete data
– 4% missing data; 6% stopped submitting data
• Sensitivity analysis yielded similar results
• Results reported through 28-30 months postimplementation
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Michigan Keystone ICU –
Bundle Adherence
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Michigan Keystone ICU
Infect Control Hosp Epidemiol. 2011;32(4): 305-314.
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Michigan Keystone ICU
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Principles of Safe Design Apply to
Technical and Teamwork
Communication
breakdowns are
frequently the root
cause of…
undesirable
outcomes
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Teams Make Wise Decisions When
There is Diverse and Independent Input
• Wisdom of Crowds
• Redundancy is two sets of eyes trained
differently looking at same picture
• Structured communication tools linked to
improved patient and economic outcomes
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Structured Communication
• Briefings and Debriefings
– Reductions in complications;
mortality 1,2
• Daily goals
– 654 new ICU admissions; $7 million
additional revenue 3
1
2
3
N Engl J Med 2009;360:491-9.
JAMA 2010;304(15):1693-1700.
J Crit Care 2002;18(2):71-5.
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Summary
• Safety is a property of systems
• Standardize, create checklists, learn when things
go wrong
• We need lenses to see the system
• Recognize these principles apply to
technical and team work
• Teams make wise decisions when there is
diverse and independent input
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Action Items
• Have all staff, unit leadership and executive
leaders view the Science of Improving Patient
Safety video
• Put together a roster of who needs to view the
Science of Safety video, establish a timeline for
completion and track progress
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Finalize enrollment
• Complete and submit the
commitment/enrollment form
• Questions or comments:
– Karol G. Wicker, MHS
Senior Director, Quality Policy & Advocacy
Maryland Hospital Association
[email protected]
– Mary Catanzaro RN BSMT CIC
Project Manager HAIs
Hospital and Healthsystem Association of Pennsylvania
[email protected]
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References
Slide 6
1. Bates DW, Cullen DJ, Laird N, Peterson LA, Small SD, Servi D,
Laffel G, Sweitzer BJ, Shea BF, Hallisey R, et al. Incidence of
adverse drug events and potential adverse drug events. Implications
for prevention. ADE Prevention Study Group. JAMA. 1995 Jul
5;274(1):29-34.
2. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov
R, Cotev S. A look into the nature and causes of human errors in the
intensive care unit. Crit Care Med. 1995 Feb;23(2):294-300.
3. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T,
Siegler M. An alternative strategy for studying adverse events in
medical care. Lancet. 1997 Feb 1;349(9048):309-13.
4. Kohn LT, Corrigan JM, Donaldson MS. Committee on Quality of
Health Care in America, Institute of Medicine. The National
Academies Press. 2000.
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