Ts module 1_slides_introduction_06.1 vic_final2
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Ts module 1_slides_introduction_06.1 vic_final2 Ts module 1_slides_introduction_06.1 vic_final2 Presentation Transcript

  • Strategies and Tools to Enhance Performance and Patient Safety
  • Ice Breaker
  • Sue Sheridan Video
  • Video Discussion
    • How are patients harmed as a result of medical errors?
    • How can we prevent medical errors?
    • What are the solutions?
    … Improved teamwork and communications… Ultimately, a culture of safety
  • Objectives
    • Describe the TeamSTEPPS training initiative
    • Explain your organization’s patient safety program
    • Describe the impact of errors and why they occur
    • Describe the TeamSTEPPS framework
    • State the outcomes of the TeamSTEPPS framework
  • Teamwork Is All Around Us
  • Introduction
    • Evolution of TeamSTEPPS
    Curriculum Contributors
    • Department of Defense
    • Agency for Healthcare Research and Quality
    • Research Organizations
    • Universities
    • Medical and Business Schools
    • Hospitals—Military and Civilian, Teaching and Community-Based
    • Healthcare Foundations
    • Private Companies
    • Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM)
    • “ Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies ”
    Team Strategies & Tools to Enhance Performance & Patient Safety
  • The Components of a Patient Safety Program
  • Course Agenda
    • Module 1 — Introduction
    • Module 2 — Team Structure
    • Module 3 — Leadership
    • Module 4 — Situation Monitoring
    • Module 5 — Mutual Support
    • Module 6 — Communication
    • Module 7 — Summary — Pulling It All Together
  • Introductions and Exercise: Magic Wand If I had a “ Magic Wand ” and could make changes within my unit or facility in the areas of patient quality and safety …
  • Why Do Errors Occur — Some Obstacles
    • Workload fluctuations
    • Interruptions
    • Fatigue
    • Multi-tasking
    • Failure to follow up
    • Poor handoffs
    • Ineffective communication
    • Not following protocol
    • Excessive professional courtesy
    • Halo effect
    • Passenger syndrome
    • Hidden agenda
    • Complacency
    • High-risk phase
    • Strength of an idea
    • Task (target) fixation
  • Quality in Australian Healthcare Study
      • Impact of Error:
      • Up to 16% of admissions associated with an adverse event
      • 51% considered preventable
      • 18% cause death or disability
      • The number of iatrogenic deaths exceeds the road toll
    Cost associated with medical errors is $ 2 Billion per year (pre 2000) Action : Reporting of Sentinel Events Root Cause Analysis/ AIMS analysis Patient Safety Report Safety and Quality Projects – Clinical Practice Improvement Human Factors Engineering SA S&Q Council Action Areas Commission Priorities
  • Medical Errors Still Claiming Many Lives
            • … little progress towards the goal
            • Leape and Berwick, JAMA May 2005
  • Why Teamwork and Communication?
      • Clinical handover is a high risk scenario for patient safety. Dangers include discontinuity of care, adverse events and legal claims of malpractice (Wong et al, 2008).
      • Survey of Australian doctors revealed that 95% believed that there were no formal or set procedures for handover (Bomba and Praska, 2005).
      • An Australian study of emergency department handover found that in 15.4% of cases, not all required information was transferred, resulting in adverse events (Ye et al, 2007).
      • A detailed analysis of nursing handover revealed that some handovers promote confusion and did not assist in patient care (Sexton et al, 2004).
      • Handover is among the most common cause of malpractice claims in the USA, especially among trainees, accounting for 20% of cases (Singh et al, 2007).
  • Sentinel Events in Victoria – contributing factors from RCA
      • Communication between the team e.g. clinical handover
      • Communication between staff and patient/family
      • Cultural diversity (involvement of interpreters) 1
    Communication was cited in sentinel events RCA reports as a major contributing factor from 2002/03 (16% of reports) to 2008/09 (20% of reports) and related to: 1. www.health.vic.gov.au/clinrisk/downloads/sentinel_event_program_0809.pdf (accessed 27/9/2010)
  • What Comprises Team Performance? Knowledge Cognitions “Think” … team performance is a science…consequences of errors are great… Attitudes Affect “Feel” Skills Behaviors “Do”
  • Outcomes of Team Competencies
    • Knowledge
      • Shared Mental Model
    • Attitudes
      • Mutual Trust
      • Team Orientation
    • Performance
      • Adaptability
      • Accuracy
      • Productivity
      • Efficiency
      • Safety
  • Teamwork Actions
    • Recognize opportunities to improve patient safety
    • Assess your current organizational culture and existing Patient Safety Program components
    • Identify teamwork improvement action plan by analyzing data and survey results
    • Design and implement initiative to improve team-related competencies among your staff
    • Integrate TeamSTEPPS into daily practice.
    “ High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."