Soaring Over the Safety Chasm
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See some of the documented results achieved by hospitals implementing LifeWings patient safety system.
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Soaring Over the Safety Chasm
- 1. Results Better Care & Outcomes Greater Efficiency & Reliability Fewer Errors, Less Rework and Waste Better Teamwork & Teams
- 2. Teamwork
- 3. Source: University of Texas Medical Branch - Galveston; OR
- 4. Safety Climate Survey Results Staff will freely speak up if they see anything that will negatively affect patient care Before CRM After CRM Source: Nebraska Medical Center; ED 69% 93%
- 5. Safety Climate Survey Results In this unit we discuss ways to prevent errors from happening again Before CRM After CRM Source: Nebraska Medical Center; ED 43% 94%
- 7. Nurse turnover as low as 2%
- 8. Teamwork Drives Patient Satisfaction* Patient “Excellent” & “Would Recommend” Responses r = 0.973
- 9. Teamwork vs O/E Mortality* Teamwork controls 1/3 of variability in monthly O/E mortality R = 0.586 R 2 = 0.343 P < 0.0004: Y = -1.71X + 1.76
- 11. Percentage of Uneventful Cases Before CRM After CRM Source: Nebraska Medical Center; Cath Lab 21% 62%
- 12. Main OR Turnover Time Percentage of turnovers in less than 30 minutes Before CRM After CRM Source: UTMB; OR 37% 62%
- 14. No correlation with type or size of hospital, annual CV case volume, or surgeon experience. Source: Pisano, Bohmer, Edmondson Harvard Business Review 9-696-015
- 15. Fewer Errors
- 16. Reduction in Surgical Pt. “Harms” Days between Events CRM training & Tools Implementation
- 17. 50% reduction in open claims files for potentially compensable events
- 18. Reduced Malpractice Costs 32% Reduction in Claim $’s per Surgical Discharge Pediatrics Surgery Medicine
- 20. WHO Surgical Safety Checklist Results* *Haynes AB. N Engl J Med 2009;360:491-9. P < 0.001 P < 0.003 P = NS P < 0.047 P < 0.001
- 22. IHI Perinatal Triggers Better Care & Outcomes Source: Salem Hospital
Editor's Notes
- www.SaferPatients.com These are a listing of the type of results that can be gained form CRM training… Client reported results are from our clients. Their results can be verified by the client. (I will be happy to put you in touch with a reference.) It is important to note that you don’t get these results without a commitment to both training in team skills/behaviors AND implementing “systems” that require the use of those skills… SOFTWARE plus HARDWARE.
- These data cover 32 months, about 14,000 survey responses. I took the % excellent for each month, of the adult hospital, inpatient service. The total number of discharges sampled was almost 98K. Because responses for each question that is not Excellent can range from Good, to Average, to Fair, to Poor, I wanted to get some idea when the lack of excellent was really fair or poor. Hence, I subtracted the % Fair and % Poor scores from the % Excellent. That % is correlated with monthly O/E Mortality. The correlation is 0.586. Statistically, this is a highly significant correlation. The amount of month to month variability in O/E Mortality is measured by R squared, or approximately 34%. This is the methodology Eduardo did to show the impact his training had on error reduction. If the correlation between training effectiveness and error reduction in a test sim is 0.5, then he can say that 0.25 or 25% of the error reduction was due to his intervention. One could argue that when things are really screwed-up, patients notice and that’s the very time more errors occur. We’ve not proven that by fixing teamwork, we can reduce medical error and O/E mortality, but there’s nothing I’ve ever seen that has such a high correlation. It’s certainly worth looking at, given the virtual absence of risk in training to improve teamwork.
- www.SaferPatients.com
- www.SaferPatients.com
- Didn’t know date of last wrong surgery.
- www.SaferPatients.com
- WHO Surgical Safety Checklist results as cited
- www.SaferPatients.com
- www.SaferPatients.com The Perinatal Trigger Tool provides instructions for conducting a retrospective review of patient records using triggers to identify possible adverse events. The tool defines an adverse event as any physical harm to the infant or mother, limiting the definition of adverse events to physical rather than emotional harm. The use of triggers to identify adverse events during a manual chart review has been used extensively to measure the overall level of harm in a health care organization. Recent publications describe the process for the review and the history of triggers to identify events. (Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Quality and Safety in Health Care. 2003;12;Suppl 2:39-45.) (Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: A practical methodology for measuring medication related harm. Quality and Safety in Health Care. 2003;12:194-200.) The Triggers used for this Chart are: T1 Apgar < 7 at 5 min. T2 Admission to NICU and >24 hours T3 Maternal/Neonatal Transport T4Terbutaline T5 Naloxone T6 Infant Serum Glucose <50 T7 3rd or 4th Degree Lacerations T8 Prolonged Decelerations T9 Blood Transfusion T10 Platelet count <50,000 T11 Abrupt Medication Stop (e.g. epidural) T12 Hypotension/Lethargy (Mom e.g. OD on Mag SO4) T13 Transfer to a Higher Level of Care, including ICU inhouse T14 Unplanned Return to Surgery T15 Estimated Blood Loss > 500 mL T16 Specialty Consult T17 Administration of Oxytocic Agents Post-delivery (such as oxytocin, ergonovine, methylergonovine, and 15-methyl-prostaglandin) T18 Instrumented Delivery T19 Administration of General Anesthetic for Delivery T20 Cord Gases Ordered T21 Gestational Diabetes T22 Other IHI strongly discourages using this data for benchmarking. The purpose of the trigger tool is to determine the rate of harm within your own organization. Based on the selection methodology and the subjective review of the charts, the resulting harm rate will not serve as a benchmark. We do encourage organizations to contact those whose harm rate is lower to determine what efforts have driven down that rate. You will notice some fluctuation in rates. This may be due to the sampling methodology. The definition of harm is “Would you want this event to happen to you or your loved one?” The tool is not designed to differentiate between preventable and non-preventable harm. Harm, once considered “the cost of doing business” must now be considered as an undesirable event for the patient. View events from the patient’s perspective.
- Varying Results Attributed to Teamwork Climate Michigan’s Key Stone Project achieved varying degrees of results. While some hospitals achieved greater lengths of time without bloodstream infections, others did not. Why the variance ? Hospitals reporting a higher level of teamwork communication and collaboration through their AHRQ Safety Climate Surveys also achieved a greater number of months without blood stream infections. The key variable in getting better results was identified as the team’s ability to cross check, communicate and collaborate. Essentially, all of the hospitals involved in the Key Stone Project implemented the major elements of a Crew Resource Management (CRM) program, as adopted from other high reliability organizations, including leadership development, teamwork training, and safety tools. www.SaferPatients.com 1-800-290-9314