Introduction to the science of improving patient safety

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  • 2/18 Josie started was febrile and began vomiting. 2/19- confirmed CLABSI. Started on oral antibiotics Josie continued to vomit and have diarrhea (attributed to Ab) Josie’s mom appealed to RNs and MDs to give her fluid (po or IV) but requests were denied Josie’s mom gave her a bath in the evening, Josie was thinner and she was sucking on a washcloth for fluid. Upon return to bed, Josie’s eyes rolled back in her head. An attempt by mom and RNs to get MDs to look at Josie failed.
  • Introduction to the science of improving patient safety

    1. 1. Introduction to the Science ofIntroduction to the Science of Improving Patient Safety, JustImproving Patient Safety, Just Culture and Safe Patient Handling &Culture and Safe Patient Handling & MobilityMobility Dennis Jones, DNP, RN, NREMT-P Safety & Quality Officer Lifeline Critical Care Transport Team Johns Hopkins Hospital Instructor – JHUSON
    2. 2. Learning ObjectivesLearning Objectives • To recognize that every system is designed to achieve the results it gets • To identify the basic principles of safe design that apply to both technical and team work • To discuss how teams make wise decisions To identify the basic purpose of a Comprehensive Unit - based Safety Program (CUSP) team The content for the above objectives from Department of Patient Safety – Johns Hopkins Hospital. Used with permission. • To discuss the rationale for, and identify components of, Safe Patient Handling & Mobility (SPHM) Interprofessional National Standards • Identify a variety of assist devices to be used in SPHM.
    3. 3. The problem of keeping patients safeThe problem of keeping patients safe is largeis large In U.S. Healthcare system • 7% of patients suffer a medication error • Every patients admitted to an ICU suffer adverse event • 44,000- 98,000 deaths • $50 billion in total costs • Similar results in UK and Australia Kohn To err is human
    4. 4. The image of Patient Safety for JHHThe image of Patient Safety for JHH Josie King – 18 months old • Admitted to JHH January 2001 after suffering 60% BSA (2nd degree, or partial thickness burns) • Josie stayed in JHH PICU from admission to just before Valentines day when she was moved to IMCU. • Pt developed vomiting, and diarrhea, confirmed CLABSI. Placed on oral Antibiotics (no IV access) and eventually became dehydrated, lethargic and unresponsive. Treated with Narcan, and Josie was allowed to drink (1 liter of fluid). Methadone was d/c’d. • Per mom, Josie continued to look bad, and a pain specialist thought she should return to PICU but attending surgeon said no. Pain specialist recommended ½ original dose of methadone to prevent withdrawal. 1 dose of oral Methadone given. Pt went into cardiac arrest, resuscitated for long period. Was brain dead and removed from life support on 2/22.
    5. 5. How can such an event happen? • People are fallible • Medicine is still treated as an art, not science • Need to view the delivery of healthcare as a science • Need systems that catch mistakes before they reach the patient
    6. 6. How Can We Improve?How Can We Improve? Understand the Science of SafetyUnderstand 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 blameCaregivers are not to blame
    7. 7. Case study Central line removal •A woman with metastatic cancer was hospitalized in the intensive care unit (ICU) for management of congestive heart failure and acute-on-chronic renal failure. The nephrology service initiated continuous venovenous hemodialysis through a large-bore catheter inserted in the right internal jugular vein. Two weeks later, a first-year renal fellow removed the catheter while the patient was seated upright in a chair. The patient became acutely hypoxemic and appeared to seize. Head imaging revealed global central nervous system ischemia suspicious for hypoperfusion. The patient survived but had neurological deficits and died about 6 months later.
    8. 8. SystemSystem FailureFailure LeadingLeading toto ThisThis ErrorError Catheter pulled with Patient sitting Communication between resident and nurse Lack of protocol For catheter removal Inadequate training and supervision Patient suffers Venous air embolism 8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004. 9. Reason J, Hobbs A., 2000.
    9. 9. This is a test…This is a test…
    10. 10. What’s wrong with this picture?
    11. 11. What’s wrong with this picture?
    12. 12. What’s wrong with this picture?
    13. 13. What’s wrong with this picture?
    14. 14. What’s wrong with this picture?
    15. 15. Pharmacy Carbon Original
    16. 16. What’s wrong with this picture?
    17. 17. System Factors Impact SafetySystem Factors Impact Safety HospitalHospital Departmental FactorsDepartmental Factors Work EnvironmentWork Environment Team FactorsTeam Factors Individual ProviderIndividual Provider Task FactorsTask Factors Patient CharacteristicsPatient Characteristics InstitutionalInstitutional 10. Adapted from Vincent C, Taylor- Adams S, Stanhope N., BMJ, 1998.
    18. 18. Principles of Safe DesignPrinciples of Safe Design • Standardize – Eliminate steps if possible • Create independent checks • Learn when things go wrong – What happened – Why – What did you do to reduce risk – How do you know it worked
    19. 19. Standardize - Line Cart ContentsStandardize - Line Cart Contents
    20. 20. Eliminate StepsEliminate Steps
    21. 21. Create Independent ChecksCreate Independent Checks
    22. 22. Principles of Safe Design Apply toPrinciples of Safe Design Apply to Technical and Team WorkTechnical and Team Work
    23. 23. Basic Components and Process ofBasic Components and Process of CommunicationCommunication 16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.
    24. 24. Teamwork ToolsTeamwork Tools • Staff Safety Assessment • Daily goals • AM briefing • Shadowing • Barrier Identification and Mitigation • Learning from Defects
    25. 25. SystemsSystems • Every system is designed to achieve the results it gets • To improve performance we need to change systems • Start with pilot test  one patient, one day, one provider, one RN, one room
    26. 26. Comprehensive Unit-based Safety Program (CUSP)Comprehensive Unit-based Safety Program (CUSP) AnAn Intervention to Learn from Mistakes and Improve Safety CultureIntervention to Learn from Mistakes and Improve Safety Culture 1. Educate staff on science of safety http://www.hopkinsmedicine.org/quality_safety_research_group/ 1. Identify defects 2. Assign executive to adopt unit 3. Learn from one defect per quarter 4. Implement teamwork tools Timmel J, et al. Jt Comm J Qual Patient Saf 2010;36:252-260.
    27. 27. RecapRecap • Accept that we will make mistakes • Develop lenses to see systems and design to make them safer • Value the wisdom of frontline staff • Work to standardize one process • Infuse these principles of standardization and independent checks in other processes • Recognize culture is local • Seek to expose (not hide) defects • Don’t play man down – Speak up when you have a concern – Listen when others do
    28. 28. SPH&M “The incidence rate of back injuries among nurses is more than double that among construction workers, perhaps because misperceptions persist about causes and solutions.” Nelson, A.; Fragala, G.; Menzel, N. (2003). Myths and Facts About Back Injuries in Nursing. American Journal of Nursing. 103(2), 32-40. “A healthcare professional is the only professional who considers 100 pounds, light”. “If you have a 300 pound container in a warehouse that needs to be moved, how is it done?” – forklift “If you have a 300 pound patient in a hospital that needs to be moved, how has it traditionally been done?” – you get more people. D. Jones
    29. 29. SPH&M • Manual handling/lifting of patients • How much can (should) we lift? • What are barriers to not manually handling/lifting of patients? • What are the potential negative outcomes to manual lifting? • So what do we do about it?
    30. 30. SPH&M – ANA Interprofessional National Standards 1. Establish a culture of safety 2. Implement and sustain a SPH&M program 3. Incorporate ergonomic design principles to provide a safe environment of care 4. Select, install, and maintain SPHM technology 5. Establish a system for education, training, and maintaining competence 6. Integrate Pt-centered SPHM assessment, plan of care, and use of SPHM technology 7. Include SPHM in reasonable accommodation and post- injury return to work 8. Establish a comprehensive evaluation system
    31. 31. Examples of SPHM technology Maxi-Move lift Maxi-move with patient
    32. 32. Examples of SPHM technology Maxi – Sky ceiling lift Maxi – Sky ceiling lift with patient
    33. 33. Examples of SPHM technology • Kreg Bariatric E-Z Wider bed: http://kreg.us/VideoArchive/EZWider/full/EZ2.7/index.cfm • Air assisted lateral transfer device
    34. 34. Conclusion • Be aware of systems issues as you go through nursing school • Think safety, for the patient AND you. • Take the time to get help, appropriate equipment when moving patients • Get involved in safety & quality committees initiatives within your organization

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