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Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
Establishing safety event analysis team seat turned ordinary people in to champions
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Establishing safety event analysis team seat turned ordinary people in to champions

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Back ground …

Back ground
Tawam hospital faced many of the same barriers to patient safety present in hospitals elsewhere. The Leadership realized that the best way to enhance patient safety is to build a Culture of Safety at the hospital and hence has been implementing the Johns Hopkins Comprehensive Unit based Safety Program (CUSP). CUSP started as a pilot project in 2008 and now being implemented in ten units. Prior to implementation the leadership decided to measure staff perception of safety using evidence based tool.

Method
The Safety Attitudes Questionnaire (SAQ) was administered to all Tawam Hospital staff in three phases understand staff perception of safety. SAQ measures culture along 7 dimensions. The survey results are graded against percentage positive responses.

Results
A comparison of the SAQ’s pre & post CUSP implementation. ICU and Pediatric Oncology had six domains in the danger zone. NNU had four domains in the danger zone.
2010 & 2011 SAQ survey, the overall hospital score on all the domain scores were in the danger zone. 20 clinical locations in 2010 and 7 clinical locations in 2011 had less than 60% scores in the primary dependent variables.

Conclusion
SAQ results were disseminated department wise in the presence of a hospital Senior Executive. The unit staff selected one or two areas of concern and developed action plans for improvement.
CUSP was rolled out in Six more units. Safety Analysis Teams have been established in the CUSP pilot units to analyze and learn from defects.

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  • 1. Establishing Safety Event Analysis Team (SEAT) “turned ordinary people in to champions” Presented at The Johns Hopkins Fifth Annual Patient Safety Summit Baltimore -June 6, 2014 Presented By Krishnan Sankaranayanan MS, MBA, CPHQ, FASHRM Senior Safety Officer / Tawam Hospital
  • 2. Disclosure The presenter has nothing to disclose, nor has any commercial interest with any of those information's displayed in this presentation. 2014/7/13 2
  • 3. About Tawam Hospital • Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in the middle of the desert, and one among the largest healthcare facilities in the United Arab Emirates. • In 2006 the General Authority of Heath Services now called as the Abu Dhabi Health Services Company PJSC (SEHA) entered in to a ten year affiliation contract with Johns Hopkins Medicine. • Tawam Hospital has current status with – Joint Commission International Accreditation (2006; 2009; 2012), – College of American Pathology (CAP; 2011) and – American College of Graduate Medical Education- International (ACGME; Program Accreditation) 2014/7/13 3
  • 4. Discussion items • Non-punitive approach to error reporting. • Culture of safety survey scores and event reporting linkages. • Creating a process to help frontline staff report incidents and learn lessons out of it.
  • 5. Summit Theme-"In Pursuit of High Reliability HRO principles • Aligns with all the five principles of high reliability 1. Sensitivity to operations 2. Reluctance to simplify 3. Preoccupation with failure 4. Deference to expertise 5. Resilience
  • 6. “Quote” “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” (Leape 2009) Dr. Lucian Leape is a professor at Harvard School of Public Health, he is a health policy analyst whose research has focused on patient safety and quality of care
  • 7. http://www.jointcommission.org/assets/1/18/Root _Causes_by_Event_Type_2004-2Q2013.pdf Sentinel Event Data - Root Causes by Event Type April 15, 2014
  • 8. 2014/7/13 8
  • 9. 2014/7/13 9
  • 10. Greatest Challenge at Tawam • Employees hail from 60 nations • Hierarchies between providers • A culture that isn’t accustomed to acknowledging medical errors. • Tendency for poor communication and teamwork that lead to adverse events Tawam had a history- “you made a mistake, and you’re terminated.”
  • 11. When errors occur one of the three things happen • It can cause the person to become a champion Or • It can cause the person to leave the profession prematurely Or • It can make the person go in to a shell and feel completely withdrawn and Disengaged. 2014/7/13 11
  • 12. Data source • Culture of safety assessment surveys • Incident Reporting system • System changes initiated through SEAT • Celebrating Safety- Staff recognition
  • 13. SAQ’s 2008 & 2010 (ICU CUSP)
  • 14. Safety Event Analysis Teams- SEAT –A team of believers & opinion builders –Team identified defects from Patient Safety Net (PSN) –Implemented systems changes to reduce the probability of recurring. –At least one defect was investigated each month. 2014/7/13 15
  • 15. System changes –Medication Cabinet Verbal order carried out against policy for Narcotic medication. (Fentanyl Patch) – Analyzed usage of each Narcotic and Controlled medication (for the previous six months). – Determined Critical/emergency need of each drug. – Reduced the inventory of the Narcotic and Controlled by 50%. (reduced risk by half) – ICU physicians and nurses informed about the changes. – Periodical review of the usage being carried out. 2014/7/13 20
  • 16. System changes – CVL pull • Action to secure the Central Line –Implemented loop dressing to secure the lines. –Monitored effectiveness of the system change. –Wherever possible considered removing the CVL. –Had no incidents thereafter.
  • 17. Staff recognition In the picture: Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna 2014/7/13 22
  • 18. System changes -Pressure Ulcers • 9 PU’s reported between Oct 2011 &Mar 2012 – Joint investigation conducted by wound care nurse and wound care link nurse. – Developed Nursing care plans. – Conducted one to one education. – Involved Respiratory Therapists. – Introduced • Change in policy • BIPAP vacations • Gel masks to prevent device related PU’s.
  • 19. Staff recognition -Wound care & RT In the picture: Priya Padmanabhan; Stephanie Woodworth; Lynn Petrie; Krish and Dr. Said Abuhasna
  • 20. System changes Misplaced CVL • Patient had a central line inserted in the ED and arrived in the ICU. • The nurse was not sure about the position of the catheter. • ICU doctor checked the chest X-ray done in ER – showed improper position • Found to be an arterial line. • Action: – Post procedure X-ray to be done and the position to be confirmed prior to shifting patient. – Post procedure VBG to be checked.
  • 21. Staff recognition In the picture: Steve CUSP Executive, Lynn Petrie; Dr. Masood and the RN Sosamma Saji
  • 22. 4 7.6 10.8 0 1.1 1.3 3 3.55 2.2 4.4 1.2 5.3 1.6 5.4 3.8 0 8.6 4.2 1.6 4.5 0 1.5 6.8 3.1 3.6 5.7 1.4 2.9 3.9 2.9 4.1 5 6.1 5.7 2 4.7 1.2 2.7 2.2 00 2 4 6 8 10 12 Blood Culture Contamination Study- ICU CUSP % Contaminated % CLSI Benchmark Linear (% Contaminated ) Re-education and audits Causative factors (Baseline assessment) • Improper hand washing • Improper site cleaning method prior to collection • Improper site of collection • Not adhering to PPE’s Action • Group demonstrations • One to one staff education • Audits Causative factors New hires lack of orientation American Society for Microbiology & Clinical Laboratory Standards Institute benchmark for the maximum acceptable contaminated blood culture is 3%. Re-education and audits Created teams for blood draws Prevention skill fair Causative factors Sustainability
  • 23. Staff recognition Maryan Dimaano Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for being part of the blood culture contamination reduction project.
  • 24. Staff recognition Maria Gomez Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for being part of the blood culture contamination reduction project.
  • 25. Staff recognition Lali Varghese Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for being part of the blood culture contamination reduction project.
  • 26. Staff recognition Shanthi Subramanian Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for catching a near miss medication error, that resulted in a system change in the pharmacy.
  • 27. ICU-CUSP Jasmin Jamilan Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for catching a near miss medication error.
  • 28. Implications of SEAT • The staff came open and reported the incidents • It helped institute a Fair and Just Culture • Investigation examined the processes and not just people. • Staff share their experiences with other CUSP units. • SEAT helped turn these staff in to champions. 342014/7/13 Broke the myth “you made a mistake, you don’t get terminated.”
  • 29. Increasing trend in reporting
  • 30. HSOPS 2012 & 2013 (ICU CUSP)
  • 31. May 2014 ICU CUSP Completed Six Years
  • 32. References • Leape LL. Testimony, United States Congress, House Committee on Veterans' Affairs; 1997 Oct 12. • Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32:102- 108. • Wolf, Z.R & Hughes, R.G. “Error reporting and disclosure”. In Hughes, R.G (Ed). Patient Safety and Quality. An Evidence-based handbook for Nurses. 2008; 35: 333-379.
  • 33. Thank You Patient Safety Top Priority Patient Safety Everyone's Responsibility Contacts: ksankara@tawamhospital.ae +971 50 9211649

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