Emily Pasola MSN, RN, CNL
Clinical Nurse Leader
St. Joseph Mercy Health System
Ann Arbor, MI
[email protected]
•June 11, 2015
Learning Objectives
• Review the principles of the Science of Safety
• Identify strategies to identify defects
• Understand components of Staff Safety
Assessment (SSA)
• Discuss plan to educate staff on Science of
Safety & SSA
2
Continuing Your Journey
May 7th meeting
Next Steps
• Team formation
• Determine roles
• Determine meetings
• Set goals
What can CUSP do for you?
Overarching Goal
•
•
•
•
Reducing Harm
Teamwork
Patient Safety
Culture of Unit Safety
Learn from defects
4
How will we get there?
Key concepts: Adaptive and Technical Work
Technical
Work
Sweet
Spot
Adaptive
Work
(CUSP)
5
Steps of CUSP
Adaptive /Cultural
Technical
CUSP
Clinical
1) Understand & EducateScience of Safety
2) Identify DefectsStaff Safety Assessment
3) Partner w/ Executive
Leaders
4) Learn from Defects
CAUTI Prevention
CLABSI Prevention
5) Teamwork & Communication-
Implement tools
www.ahrq/cusp
6
How Do Errors Happen?
• Multiple factors
• People are fallible
• Flawed system design
• Medicine treated an art, not
science
7
“Medical errors most often result
from a complex interplay of
multiple factors. Only rarely are
they due to the carelessness or
misconduct of single individuals”
Lucien L. Leape, MD
Harvard School of Public Health
Why Do Mistakes Happen?
•
•
•
•
•
•
•
Variable input (diff pts)
Inconsistency/variation
Complexity
Too many steps
Human intervention
Tight time constraints
Hierarchical culture
Process Factors
•
•
•
•
•
•
•
Fatigue
Inattention/distraction
Unfamiliar situations
Past solutions/Old habit
Equipment flaws
Communications errors
Inadequate instructions
People Factors
9
A Medication Error Story
Nurse borrows
medication from
another patient
Working w/o
enough staff
Patient receives
a medication to which he
is allergic
System for ordering
medications
Patient arrests and diesHarm reached the patient:
process & people factors
Tube system
for obtaining
medications
is broken
is broken
Reason
10
• System set up determines performance
• Need strategies to improve system
performance
–Standardize
–Create independent checks for key
process
–Learn from mistakes
• Apply strategies to both technical & team
work
• Recognize that teams make wise decisions
11
IOM (Institute of Medicine)
Basic Components of Patient Safety
• User Centered Design
– Visibility
– Affordance
– Constraints & Force Function
• Avoid Reliance on Memory
– Simplify necessary steps
– Minimize on the spot problem solving
• Central line carts
– Take out the “guess” work
• Attend to Work Safety
– Evaluate working conditions
– Identify potential distractions
• No Interruption Zones
12
IOM
Basic Components of Patient Safety
• Avoid Relying on Vigilance
– Working harder doesn’t make things safer
– Effective alarms
– Lunch breaks, rotating staff
– Checklists
• Training for Team Collaboration
– Communication Tools
– Strategies to problem solve
• Involving Patients in Their Care
– Center of the team
– Creating goals and plans of care
13
IOM
Basic Components of Patient Safety
• Anticipate the Unexpected
– Errors increase with organizational changes—IE: CPOE
– New technology introduces new potential sources of error
• Design for Recovery
– Assume that errors will occur- design and plan for recovery
– Use simulation training to practice recovery strategies
• Improve Access to Timely Information
– Information for patient care decisions should be available
at the point of patient care
14
Communication is Key
• Effective communication amongst caregivers is essential
for a functioning team
• The Joint Commission reports that ineffective
communication is the most commonly cited cause for a
sentinel event
• Observations of ICU teams have shown errors in the ICU
to be concentrated after communication events (shift
change, handoffs, etc.)---• 30% of errors are associated with communication
between nurses and physicians
Reader, CCM 2009 Vol 37 No 5; Donchin
CCM 1995 Vol 23
15
Importance of Communication
Ineffective communication is a root cause for
greater than two-thirds of all sentinel events
reported
Source: The Joint Commission’s Root Causes and Percentages for
Sentinel Events (All Categories) January1995−December 2008
16
Effective Communication &
Teamwork Requires:
• SBAR, structured handoffs
• Structured
Communications
• Key words at key times, the ability to speak up and stop the show
• Assertion/Critical
Language
• An environment of respect just culture
• Psychological
• Flat hierarchy, sharing the plan, continuously inviting the other team
Safety
•
members into the conversation, explicitly asking people to share questions
or concerns, using people’s names.
Effective
Leadership
17
How Can We Improve?
Understand the Science of Safety
• Every system is perfectly designed to achieve the results it gets
• 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
Caregivers are not to blame
18
Strategies to Identify Defects
Staff Safety Assessment
2 questions
– Please describe how you
think the next patient in
your unit/clinical area
will be harmed
– Please describe what you
think can be done to
prevent or minimize this
harm
• Past sentinel events
• Current outcome
dashboard
• Incident Reports
• Patient Satisfaction
Surveys
• Patient complaints
19
Strategies to Educate on
Science of Safety
Content:
• Use slides 5-17
• Use videos on internet
– Science of Safety
https://armstrongresearch.hopkinsmedicine.org/cusp4mv
p.aspx
– Safety as a System
http://www.dukepatientsafetycenter.com/ under online
resources
• Administer Staff Safety Assessment
Method:
• Small group education
• Independent video viewing with small group debriefing
20
Next Steps
•
•
•
•
Complete steps from
Face to Face meeting
Ensure team members
understand role
Develop calendar of meetings
Next steps moving forward
Establish plan for education
– Develop content
– Create schedule
– Begin in-services
Establish method to
administer SSA
– Collate results
Timeline for Science of Safety Education &
Staff Safety Assessment
• June 11-30:
Plan content and set up
in-service schedule for Science
of Safety Education & Staff
Safety Assessment
• June 30-July 31:
Conduct in-services &
administer Staff Safety
Assessment questionnaire
• July 31-Sept 9:
Collate results of Staff
Safety Assessment
questionnaire
22