Patient Safety:
Why Bother?
Noel Eldridge, MS for
James P. Bagian, MD, PE
Chief Patient Safety Officer
Director, VA Nation...
(Jimi couldn’t make it today. You got Noel.)
James Bagian, MD, PE
Director, VHA National Center for Patient Safety
Noel El...
VA Statistics (FY 2005)
 7.7M enrollees, 5.3M uniques
 VA Medical Centers (Hospitals): 156
 Admissions: 587,000
 Commu...
Veterans Health AdministrationVeterans Health Administration
2211 Veterans Integrated Service NetworksVeterans Integrated ...
Patient Safety Background and VA
Information on Reporting
Institute of Medicine Goals
1. Safe – “avoiding injuries to patients from the care
that is intended to help them”
2. Timel...
NY Times and W. Post This Week
 Medication Reconciliation & Adverse Events
– “Unintentional drug poisonings accounted for...
Where Healthcare Was/Is
 Cottage Industry Mentality
 Virtually Total Reliance on:
– Professional/Individual Responsibili...
Where Does a
Culture of Safety Exist?
 Would you agree to fly on a bankrupt
airline to save $100?
 Would you agree to ge...
Sad Comment at amazon.com
Take this Book to the Hospital With You:
A Consumer Guide to Surviving Your
Hospital Stay
(4.5 s...
NAVAL AVIATION MISHAP RATE
776 aircraft
destroyed in
1954
FY 50-96FY 50-96
Fiscal Year
2.39
39 aircraft
destroyed in
1996
...
Three Important Questions
1. What Happened?
2. Why Did it Happen?
3. What Should We Do to Prevent it from
Happening Again?
Typical Healthcare Approach
 New Policies, Regulations,Reporting
Systems, Training
 Good First Step But…..
– Lack of Sys...
Goal Selection
 Clear
– Not Confused With Tactics
 Compelling
– Relevance To Those Who Must Take Action
– Early Stakehol...
Goal: Prevent Harm
VA Patient Safety Advisory - August 8, 2000
 Item: Medtronic Dual Chamber Temporary
Pacemaker model 53...
Typical Missing Features
 Clear Understanding of Goal
 Preventive Approach
 Field Understanding & Buy-In
 Systems Appr...
Safety System Design
 High Reliability Organizations
 Role of Reporting
– Learning or Accountability?
 Systems-Based So...
VA Patient Safety Data & Feedback
 Incidents reported have monotonically
increased since reporting to NCPS
started in 200...
VA Annual Events Reported
(including close calls) is Still Going Up
Safety Assessment Code
(SAC)
Severity &
Probability
Catastrophic Major Moderate Minor
Frequent 3 3 2 1
Occasional 3 2 1 1
...
The Value of Close Calls in Safety
Close calls can provide “sentinel” information
without or before the “Sentinel Event.”
Patient Safety System Design
Patient Safety System Design
Most VA Reports are Actual “SAC 1s”
(events with little or no harm, or close calls)
Which Events get RCAs?
 Many RCAs
are done on
events that
are not
Actual 3s.
 Numbers are
surprisingly
constant
since 20...
RCA Categories (Coded by NCPS)
Selected Event (FY 2005) for Individual RCAs Percent
Fall 13.9%
Delay in Treatment/Diagnosi...
What about the Adverse Events and
Close Calls that don’t get “RCAed”?
 In VA Aggregated Reviews are
performed at the loca...
Guiding Principles For Patient
Safety System
Learning, Not Accountability System
Reporting System Characteristics
• Non-...
What comes from RCAs?
1. Local Fixes and Learning
2. Local Insight into Better Methods for
Improvement and the Tractabilit...
VA RCA data on Incorrect Surgical
Procedures (2001 – 2005)
 In-Operating Room: 33%
 Out-of-Operating Room: 42%
 Eye Pro...
What was Wrong? (2001-2005)
26 27
16
10
22
0
5
10
15
20
25
30
Wrong
Patient
Wrong
Side
Wrong
Site
Wrong
Procedure
Wrong
Im...
VA RCA data on Retained
Surgical Items, 2000-2005
Sponge
, 52
Towel,
5
Other,
8
Human Factors and Strength of Actions
Safety & Human Error:
Challenges
 Healthcare Views Errors as Failings
Which Deserve Blame - Fault
 Train and Blame Menta...
Safety & Human Error:
Cornerstones
 People Don’t Come to Work to Hurt
Someone or Make a Mistake
 Must Keep Asking “Why?”
Safety – Human Error
Technical
Individual
Team
Profession
Institution
Policies/Procedures
Accident
LATENT
FAILURES
DEFENSE...
Patient Safety - Strategy
 Invite People to Play
– Problem Recognition
– Remove Barriers (Punitive, Difficulty, Black
Hol...
Changing Culture
Tools
Behavior
Attitude
CULTURE!!!
Prioritize
 Risk Based
– Severity
– Probability
 Must Make Sense
– Business Processes
– Regulatory Environment
Systematic
 Cause and Effect
 Human Error Must Have Preceding
Cause
 Failure to Follow Procedure By Itself Is
NOT a Roo...
Causation/Actions:
Who vs.What &Why
 Who
– ‘Whose Fault Is This?’
– Actions focused on correcting individual
– ‘Corrects’...
Intentionally Unsafe Acts
 “…events that result from: a criminal act; a
purposefully unsafe act; an act related to
alcoho...
On Being Human
Behavior Response
 When I say “up”, everyone raise
your hand as quickly as you
can
This was not an aerobic exercise
 Demonstrates: “paired associate
learning”
Medical Software Correlation
- Pharmacist uses 95% of time.
- “Enter” button enters data.
- Pharmacist uses 5% of time.
- ...
“Take-away” on Human Factors…
 Considering and acting on knowledge
regarding human capabilities,
limitations, and tendenc...
Human Factors Engineering
and “Actions”
 Warnings and labels (watch out!)
 Training (don’t do that)
 Procedure changes ...
Actions & Interventions
Stronger
Actions
• Architectural/physical plant changes
• New devices with usability testing before purchasing
• Engineeri...
Strong Action: Brake and Automatic
Transmission Connection
“Simple” Engineering Solutions at
Disneyworld Resorts (Motels)
Simple Engineering Solutions at
Disneyworld Resorts (Motels)
Now I need a car roof
that’s round!
Blue tubing does not fit here or here…it only fits here
Alert based on “wrong-tube” RCAs
 Veterans Health Administration Warning System
 Published by VA Central Office
 AL06-0...
Look-alikes (different “eye-drops”)
Sound-alikes (e.g., Flomax and Flonase)
Redundancy vs. Double-check
in Spelunking (Caving)
 Two choices of
equipment
1. One flashlight 
batteries checked twice
...
Lawnmower cut-off switch
Experience is an Expensive Teacher
Management Involvement
 Formalized, Not Ad Hoc
 Safety Permeates the Fabric of All
Activities
 Relentless
Safety System Design
Action AssessmentAssessment
 Characteristics of Actions
– Temporary vs. Permanent
– Procedural vs. Physical
 Action Eval...
Business Case for Patient Safety
Is There A Business Case?
 YOU BET!!!
 Examples:
– “Easy CAP” CO2 Detector
• $154/detected esophageal intubation
– RCA/4...
Devices to prevent Out-of-OR Esophageal
Intubations are Cost-Effective
Description Equation =
Numerator Cost to implement ...
Benefit-Cost of Patient Safety
 National Center for Patient Safety,
Regional Patient Safety Officers, Facility
Patient Sa...
Some Interventions have Zero Cost
Use of Antimicrobial Soap in VAMCs
43
19
38
3 16
81
0
10
20
30
40
50
60
70
80
90
Use Ant...
Summary and Wrap up
Sustainable Systems Approach
 Problem Identification
 Clear Goal Definition
 Involvement Of All Sectors
 Identify Syst...
Critical Elements
 Safe for Reporters/Participants
 Prioritization Method
 What is Blameworthy
 Not About Fault – 3 W’...
Closing Thoughts
 Not About Errors!!!
 Counting reports is not the objective,
identifying Vulnerabilities is
– Hope they...
Safety as the Foundation?
 Quality programs can ensure that we use
evidence-based medicine to determine
which cardiac pat...
Why Bother?
1. The Problem is Real
2. You Can Do Things to Make it
Better
“They say that time changes
things, but you actu...
Recently we have received a number of questions about whether is
it legal to buy facial tissues. At issue is whether or no...
Are we there yet?
“From a certain point forward there
is no longer any turning back. That
is the point that must be reache...
Have a Safe Trip Home!
San Diego
Presentation at 2007 Meeting of Indian Health Service in San Diego
Presentation at 2007 Meeting of Indian Health Service in San Diego
Presentation at 2007 Meeting of Indian Health Service in San Diego
Presentation at 2007 Meeting of Indian Health Service in San Diego
Presentation at 2007 Meeting of Indian Health Service in San Diego
Presentation at 2007 Meeting of Indian Health Service in San Diego
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Presentation at 2007 Meeting of Indian Health Service in San Diego

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This is based on Jim Bagian's "Why Bother" (about patient safety) presentation. Jim was invited but had a conflict so I wen to the national meeting of the Indian Health Service. I think this was maybe a 75 minute presentation. I added some things to make it personal to me like the Jimi Hendrix Experience slide and slide 81 on the "tissue issue" in VA that I helped resolve during my work on hand hygiene improvement. The audience also seemed to like my closing slide.

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  • I look a little more like Noel Redding than he does like Jimi Hendrix.
  • Bankrupt or nearly bankrupt airlines: United, US Airways, ATA. Is there really such a thing as “ The Healthcare System ” Consider adding chart on definition of system.
  • This first book has been in print for at least 15 years. Isn ’ t this kind of embarrassing? Would anyone fly on an airplane if there was a market for books like this?
  • All reporting - is in the end - voluntary
  • Do 4 or 5 times. Hit table the same time. Last time only hit table (some will raise hands).
  • Pattern recognition. Taking shortcuts. Do we have any systems where we do repetitive actions that might have more than one action? Demonstrates a low level brain response. Training yields a low level auto response, telling someone not to do something under these conditions won ’ t be effective.
  • Not a lot of evidence that this made things better. But who knows, reporting of lawnmower accidents probably is not the most accurate
  • NOTE: The $5.2M figure does NOT include PSRS. The raw budget figure for the office is $8.278m for FY05.
  • Presentation at 2007 Meeting of Indian Health Service in San Diego

    1. 1. Patient Safety: Why Bother? Noel Eldridge, MS for James P. Bagian, MD, PE Chief Patient Safety Officer Director, VA National Center for Patient Safety February 28, 2007 james.bagian@va.gov & noel.eldridge@va.gov www.patientsafety.gov
    2. 2. (Jimi couldn’t make it today. You got Noel.) James Bagian, MD, PE Director, VHA National Center for Patient Safety Noel Eldridge Executive Officer, NCPS
    3. 3. VA Statistics (FY 2005)  7.7M enrollees, 5.3M uniques  VA Medical Centers (Hospitals): 156  Admissions: 587,000  Community Based Outpatient Clinics: 708  Outpatient Visits: 57.5M  Rx Dispensed (30-day equiv): 231M  Lab Tests: 215.9M  Total FTE: 197,800
    4. 4. Veterans Health AdministrationVeterans Health Administration 2211 Veterans Integrated Service NetworksVeterans Integrated Service Networks I J 2 0 0 2N A N U A R Y W E R E IN T E G R A T E D A N D R E N A M E D V IS N 1 3 1 4 V IS N 2 3 S A N D
    5. 5. Patient Safety Background and VA Information on Reporting
    6. 6. Institute of Medicine Goals 1. Safe – “avoiding injuries to patients from the care that is intended to help them” 2. Timely 3. Efficient 4. Effective 5. Equitable 6. Patient-Centered  (from Crossing the Quality Chasm, 2001)
    7. 7. NY Times and W. Post This Week  Medication Reconciliation & Adverse Events – “Unintentional drug poisonings accounted for nearly 20,000 deaths in 2004, said the CDC, making the problem now the second-leading cause of accidental death in the United States, after automobile accidents.” • W. Post – 2/27/07 – “In August 2006, the Institute of Medicine of the National Academies released a major study on medication errors in American hospitals that found that adverse drug events harm more than 1.5 million people and kill several thousand a year, costing at least $3.5 billion annually.” • NY Times – 2/25/07
    8. 8. Where Healthcare Was/Is  Cottage Industry Mentality  Virtually Total Reliance on: – Professional/Individual Responsibility – Individual Perfection – Train and Blame  Little Understanding of Systems Relative to People and Processes – Ignorance vs. Arrogance Culturally Different!!!!
    9. 9. Where Does a Culture of Safety Exist?  Would you agree to fly on a bankrupt airline to save $100?  Would you agree to get elective surgery at a bankrupt hospital to save $100?  Are your answers different? If so, why?  Do you trust the airline “system” of regulators, managers, pilots, and mechanics in a different way than you trust the healthcare “system”?
    10. 10. Sad Comment at amazon.com Take this Book to the Hospital With You: A Consumer Guide to Surviving Your Hospital Stay (4.5 stars)  by Charles B. Inlander Buy this book with How to Get Out of the Hospital Alive (4.5 stars)  by Sheldon P. Blau, Elaine Fantle Shimberg today!  Buy Together Today: $20.34 CAN YOU IMAGINE THE EQUIVALENT FOR AN AIRLINE TRIP?
    11. 11. NAVAL AVIATION MISHAP RATE 776 aircraft destroyed in 1954 FY 50-96FY 50-96 Fiscal Year 2.39 39 aircraft destroyed in 1996 0 10 20 30 40 50 60 50 65 80 96 Angled Carrier Decks Naval Aviation Safety Center NAMP est. 1959 RAG concept initiated NATOPS initiated 1961 Squadron Safety program System Safety Designated Aircraft ACT HFC’s ClassAMishaps/100,000FlightHours
    12. 12. Three Important Questions 1. What Happened? 2. Why Did it Happen? 3. What Should We Do to Prevent it from Happening Again?
    13. 13. Typical Healthcare Approach  New Policies, Regulations,Reporting Systems, Training  Good First Step But….. – Lack of Systems Insight – Superficial Solutions (?Answers) – Inadequate Follow-Up – Lost Opportunity
    14. 14. Goal Selection  Clear – Not Confused With Tactics  Compelling – Relevance To Those Who Must Take Action – Early Stakeholder Involvement in Goal Definition  Reinforced By Leadership – Visible Participation • All levels – not hierarchical
    15. 15. Goal: Prevent Harm VA Patient Safety Advisory - August 8, 2000  Item: Medtronic Dual Chamber Temporary Pacemaker model 5388  Specific Concerns: The Medtronic Dual Chamber Temporary Pacemaker model 5388 may become inactive if a button is touched while it is in "self test" mode. If this occurs the pacemaker display freezes, will not work properly and displays an error code of 0004. At this point the pacemaker cannot be turned off. In order to correct the situation the battery drawer has to be opened. Only removal of the battery clears the error and turns the pacemaker off. It may then be restarted.
    16. 16. Typical Missing Features  Clear Understanding of Goal  Preventive Approach  Field Understanding & Buy-In  Systems Approach  Sustainability  Trust/Culture of Safety
    17. 17. Safety System Design  High Reliability Organizations  Role of Reporting – Learning or Accountability?  Systems-Based Solutions – Patient Centered – DUH!!!!  Importance of Close Calls
    18. 18. VA Patient Safety Data & Feedback  Incidents reported have monotonically increased since reporting to NCPS started in 2000.  VA inpatient mortality down ~35% from 1999 to 2006. – (Remember: “Correlation is not causation.”)
    19. 19. VA Annual Events Reported (including close calls) is Still Going Up
    20. 20. Safety Assessment Code (SAC) Severity & Probability Catastrophic Major Moderate Minor Frequent 3 3 2 1 Occasional 3 2 1 1 Uncommon 3 2 1 1 Remote 3 2 1 1
    21. 21. The Value of Close Calls in Safety Close calls can provide “sentinel” information without or before the “Sentinel Event.”
    22. 22. Patient Safety System Design
    23. 23. Patient Safety System Design
    24. 24. Most VA Reports are Actual “SAC 1s” (events with little or no harm, or close calls)
    25. 25. Which Events get RCAs?  Many RCAs are done on events that are not Actual 3s.  Numbers are surprisingly constant since 2001.  Is fewer actual SAC3s since 2001 & 2002 good news? Maybe.
    26. 26. RCA Categories (Coded by NCPS) Selected Event (FY 2005) for Individual RCAs Percent Fall 13.9% Delay in Treatment/Diagnosis/Surgery 10.7% High Alert Adverse Drug Events 10.5% Unexpected Death 7.2% Misidentification 6.3% Missing Patient 4.9% Hospital Acquired Infections 4.7% Outpatient Suicide 3.4% Correct Surgery 3.3% 65.0%
    27. 27. What about the Adverse Events and Close Calls that don’t get “RCAed”?  In VA Aggregated Reviews are performed at the local level, one per quarter on: 1. Adverse Drug Events 2. Missing and Wandering Patients 3. “Parasuicidal” Events 4. Falls – (When they are not “SAC 3” events)
    28. 28. Guiding Principles For Patient Safety System Learning, Not Accountability System Reporting System Characteristics • Non-punitive - Confidential and De-identified • Internal and External Importance of Close Call Reports Should Emphasize Narratives Interdisciplinary Review Teams About Identifying Vulnerabilities NOT Statistics Prompt Feedback Open to All Comers
    29. 29. What comes from RCAs? 1. Local Fixes and Learning 2. Local Insight into Better Methods for Improvement and the Tractability of Problems (not like the weather) 3. VA-wide Alerts and Advisories 4. Systemwide Learning and Informed policymaking
    30. 30. VA RCA data on Incorrect Surgical Procedures (2001 – 2005)  In-Operating Room: 33%  Out-of-Operating Room: 42%  Eye Procedures (can be either setting): 25%
    31. 31. What was Wrong? (2001-2005) 26 27 16 10 22 0 5 10 15 20 25 30 Wrong Patient Wrong Side Wrong Site Wrong Procedure Wrong Implant Percent EXAMPLES… Patient: Similar Diagnosis or Name Side: Other Side Similar Diagnosis Site: On Spine or Hand/Wrist Procedure: Biopsy vs. Cystoscopy Implant: Lens
    32. 32. VA RCA data on Retained Surgical Items, 2000-2005 Sponge , 52 Towel, 5 Other, 8
    33. 33. Human Factors and Strength of Actions
    34. 34. Safety & Human Error: Challenges  Healthcare Views Errors as Failings Which Deserve Blame - Fault  Train and Blame Mentality  Blind Adherence To Rules  Corrective Actions Focusing on Individual  No Blood No Foul Philosophy
    35. 35. Safety & Human Error: Cornerstones  People Don’t Come to Work to Hurt Someone or Make a Mistake  Must Keep Asking “Why?”
    36. 36. Safety – Human Error Technical Individual Team Profession Institution Policies/Procedures Accident LATENT FAILURES DEFENSES Incomplete procedures Regulatory narrowness Mixed Messages Production pressures Responsibility shifting Inadequate training Attention Distractions Clumsy Technology Deferred Maintenance
    37. 37. Patient Safety - Strategy  Invite People to Play – Problem Recognition – Remove Barriers (Punitive, Difficulty, Black Hole Effect) – Learning NOT Accountability System  Importance of Close Call  Blameworthy Definition  Training (Middle thru Top Management) Leadership At All Levels  Human Factors Approach – Tools That Guide Behavior
    38. 38. Changing Culture Tools Behavior Attitude CULTURE!!!
    39. 39. Prioritize  Risk Based – Severity – Probability  Must Make Sense – Business Processes – Regulatory Environment
    40. 40. Systematic  Cause and Effect  Human Error Must Have Preceding Cause  Failure to Follow Procedure By Itself Is NOT a Root Cause  Negative Descriptors Aren’t Actionable  Failure To Act Is not Cause Without Pre-existing Requirement To Act  Why,Why,Why
    41. 41. Causation/Actions: Who vs.What &Why  Who – ‘Whose Fault Is This?’ – Actions focused on correcting individual – ‘Corrects’ only after problem occurs – Limited scope of action and generalizability  What & Why – Actions focus on systems level causation – Widespread applicability – Stronger preventive strategy
    42. 42. Intentionally Unsafe Acts  “…events that result from: a criminal act; a purposefully unsafe act; an act related to alcohol or substance abuse by an impaired provider and/or staff; or events involving alleged or suspected patient abuse of any kind.”  Intentionally Unsafe Acts are off-limits to Patient Safety (RCA) review, everything else is within limits
    43. 43. On Being Human
    44. 44. Behavior Response  When I say “up”, everyone raise your hand as quickly as you can
    45. 45. This was not an aerobic exercise  Demonstrates: “paired associate learning”
    46. 46. Medical Software Correlation - Pharmacist uses 95% of time. - “Enter” button enters data. - Pharmacist uses 5% of time. - “Spacebar” enters data.
    47. 47. “Take-away” on Human Factors…  Considering and acting on knowledge regarding human capabilities, limitations, and tendencies when designing and operating devices and systems  Not always “common sense”
    48. 48. Human Factors Engineering and “Actions”  Warnings and labels (watch out!)  Training (don’t do that)  Procedure changes (work around that)  Interlock, lock-in, lock-out, etc (let me design it so you can not do that – forcing functions)  Is there one right action??? Weaker Stronger
    49. 49. Actions & Interventions
    50. 50. Stronger Actions • Architectural/physical plant changes • New devices with usability testing before purchasing • Engineering control or interlock (forcing functions) • Simplify the process and remove unnecessary steps • Standardize on equipment on process or caremaps • Tangible involvement and action by leadership in support of patient safety Intermediate Actions • Redundancy • Increase in staffing/decrease in workload • Software enhancements/modifications • Eliminate/reduce distractions (sterile medical environment) • Checklist/cognitive aid • Eliminate look and sound-alikes • Readback • Enhanced documentation/communication Weaker Actions • Double checks • Warnings and labels • New procedure/memorandum/policy • Training • Additional study/analysis
    51. 51. Strong Action: Brake and Automatic Transmission Connection
    52. 52. “Simple” Engineering Solutions at Disneyworld Resorts (Motels)
    53. 53. Simple Engineering Solutions at Disneyworld Resorts (Motels) Now I need a car roof that’s round!
    54. 54. Blue tubing does not fit here or here…it only fits here
    55. 55. Alert based on “wrong-tube” RCAs  Veterans Health Administration Warning System  Published by VA Central Office  AL06-012 April 6, 2006 – Item: Mix-up (wrong route of administration) of bladder irrigation with intravenous (IV) infusions – Specific Incidents: Since 2001, VA facilities have reported five cases of accidental infusion into an IV line or PICC line. Amphotericin B (Attachment #1) was given intravenously when it was intended for irrigation of the bladder via a catheter. The same adverse event could occur with Glycine. Amphotericin B and Glycine are both contraindicated in patients with kidney or liver disease and when Amphotericin B is infused via IV line, it can induce serious complications (e.g., kidney failure).
    56. 56. Look-alikes (different “eye-drops”) Sound-alikes (e.g., Flomax and Flonase)
    57. 57. Redundancy vs. Double-check in Spelunking (Caving)  Two choices of equipment 1. One flashlight  batteries checked twice 2. One flashlight  and one headlamp
    58. 58. Lawnmower cut-off switch
    59. 59. Experience is an Expensive Teacher
    60. 60. Management Involvement  Formalized, Not Ad Hoc  Safety Permeates the Fabric of All Activities  Relentless
    61. 61. Safety System Design
    62. 62. Action AssessmentAssessment  Characteristics of Actions – Temporary vs. Permanent – Procedural vs. Physical  Action Evaluation – Process – Outcome
    63. 63. Business Case for Patient Safety
    64. 64. Is There A Business Case?  YOU BET!!!  Examples: – “Easy CAP” CO2 Detector • $154/detected esophageal intubation – RCA/40person-hrs X 12RCA/yr • 0.25FTEE
    65. 65. Devices to prevent Out-of-OR Esophageal Intubations are Cost-Effective Description Equation = Numerator Cost to implement (11,000 [# of codes] x $10) $110,000 Denominator Number of recognized events (assuming 100% prevention effectiveness) 715 Cost-Effectiveness Measure $110,000 / 715 $154 Interpretation It will cost $154 to detect one unanticipated esophageal intubation ($10 per use at a rate of 6.5%)
    66. 66. Benefit-Cost of Patient Safety  National Center for Patient Safety, Regional Patient Safety Officers, Facility Patient Safety Managers, Local RCA teams ~$130k per VA Medical Center (0.1%) If this is a VA facility’s budget This is Patient Safety’s Share
    67. 67. Some Interventions have Zero Cost Use of Antimicrobial Soap in VAMCs 43 19 38 3 16 81 0 10 20 30 40 50 60 70 80 90 Use Antimicrobial Soap Only Use Non- antimicrobial Soap Only Use Both Types of Soap Percent(N=~120) Dec-03 May-04 See Hand Hygiene Tools on www.patientsafety.gov
    68. 68. Summary and Wrap up
    69. 69. Sustainable Systems Approach  Problem Identification  Clear Goal Definition  Involvement Of All Sectors  Identify Systems Influences  Identify Systems Controls  Identify Constraints  Critique – Go To Worst Critics Early On  Pilot – Volunteers First Then Others  Evaluate
    70. 70. Critical Elements  Safe for Reporters/Participants  Prioritization Method  What is Blameworthy  Not About Fault – 3 W’s  Human Factors Engineering Tools – Triage Cards, RCA Method  Concur/Not Concur (Mgmt/Leadership)  Feedback  Dedicated Patient Safety Duties
    71. 71. Closing Thoughts  Not About Errors!!!  Counting reports is not the objective, identifying Vulnerabilities is – Hope they increase –Analysis, Action, & Feedback are the key  Prevention NOT Punishment  Cultural change is the key – takes time Safety is the Foundation Upon which Quality is Built
    72. 72. Safety as the Foundation?  Quality programs can ensure that we use evidence-based medicine to determine which cardiac patients… – Are prescribed the most appropriate of many medications, and/or – Get angioplasty with or without drug-eluting or bare metal stents, and/or – Get CABG surgery  But if they get surgical site and/or urinary tract infections, and/or fall in the hospital… – Can you call this High Quality Care???
    73. 73. Why Bother? 1. The Problem is Real 2. You Can Do Things to Make it Better “They say that time changes things, but you actually have to change them yourself” Andy Warhol
    74. 74. Recently we have received a number of questions about whether is it legal to buy facial tissues. At issue is whether or not the facial tissues are considered personal items. We have discussed this issue with Department logistic and financial staff as well as VHA clinical staff. The following provides a basis for the decision that was reached: For patient-care areas and areas frequented by those who come in direct contact with patients, facial tissues should be considered similarly to other expendable supplies that VA workers may use as they perform their duties during work hours. For example, VA supplies disposable respirators, gloves, and surgical scrubs and gowns, all of which are employed by staff to protect patients from the spread of infectious agents. This type of expenditure is clearly appropriate. On the second point, recent guidance from the CDC, JCAHO, the National Health Information Center of the Department of Health and Human Services, and the American Lung Association have all included recommendations for using tissues to cover coughs and sneezes to prevent the spread of infectious agents. First among these infectious agents are viruses that cause upper respiratory infections such as cold and flu, but another agent of concern is Staph. aureus (SA), including methicillin-resistant SA (MRSA), either of which can cause skin and wound infections. Various estimates put the percentage of healthcare workers whose nasal passages are colonized with SA at about 30-40%. (The percent colonized by MRSA is not well described and seems likely to vary widely.) SA and MRSA can be expelled from the nose during a sneeze and live for days or weeks on substrates such as clothes, linens, curtains, countertops, and other environmental surfaces where they can be picked up on hands or transferred to other surfaces and eventually patients. Using a tissue to reduce the dispersion of droplets and the gross contamination of hands or clothes is imperfect but is widely recommended as a basic measure to control the spread of infectious agents. Conclusion: Facial tissues to be used in patient care areas and areas frequented by those who come in direct contact with patients can be purchased with appropriated funds. This memo should not be taken as a mandate to generate any new requirement to provide tissues in specific locations or at any pre-set density. Decisions on this topic should be made locally and incorporate local circumstances and considerations. (Agreed upon by: Fiscal, Accounting, Legal, Network Clinical Managers, Public Health, Environment of Care, Infectious Diseases, Patient Safety, in about 3 weeks.)
    75. 75. Are we there yet? “From a certain point forward there is no longer any turning back. That is the point that must be reached” - Franz Kafka
    76. 76. Have a Safe Trip Home! San Diego
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