Patient Safety Presentation

1. Dr Olufemi Aina
Consultant
Aesculapius Healthcare Consultants

2.  Young NYSC dr. in a GH, Lagos many years
ago: ordered IM drugs, nurse uncomfortable,
even though gave lower dose- respiratory
arrest, called and answered promptly.
 Young Father in a PH, Lagos: 2 years ago:
overworked nurse (esp. with reports), set up
IV line, suction didn’t work, sucked manually

3. Quality: the degree of the realisation of the
reasons that the patient has come to the care
hospital e.g. patient comes to for an operation.
Safety:results which are not the reasons for the
patient coming e.g. ‘not catching an infection’
and he is implicitly confident he will not run the
risk of this happening.
To a certain extent, ‘safety’ thus concerns ‘anti-
quality’.

4. Near Miss is defined as an act could have harmed the patient but did not do
so as a result of:
 chance e.g. patient received a contraindicated drug but did not
experience an adverse drug reaction
 prevention e.g. a potentially lethal over-dose was prescribed, but a nurse
identified the error before administering the medication
 mitigation e.g., a lethal drug overdose was administered but discovered
early and countered with an antidote.
Adverse Events cause harm to patients—causing a large number of injury,
disability, and death.
 errors of commission e.g., prescribing a medication that has a potentially
fatal interaction with another drug the patient is taking.
 errors of omission (e.g., failing to prescribe a medication from which the
patient would likely have benefited, which may pose an even greater
threat to health.

5.  Processes or structures which, when applied, reduce
the probability of adverse events resulting from
exposure to the health-care system across a range of
diseases and procedures.
 Healthcare-associated infection is a global problem
with over 1.4 million people suffering at any given
time.
 Medical errors result in numerous preventable injuries
and deaths.
 Inadequate Patient Safety Data in African Region

6. Adverse events 4% to 16% of all hospitalized patients
Developing Countries estimated 5% to 10% of patients acquire
one or more infections
Risk 2 to 20 times higher than in developed
countries.
Sentinel Events SurgicalCare- > 50% of Adverse Events,
Unsafe injections, blood and medicines
African Countries Mali 18.9%,Tanzania 14.8%, Algeria 9.8%
Drugs 25% of medicines are counterfeit, poly-
pharmacy, inappropriate use of
antimicrobials; overuse of injections, lack
of prescription guidelines, inappropriate
self-medication, non-adherence to
dosing regimes.

7. 7
2006
Patient Safety and
Quality
Improvement
Act of 2005
Executive Memo
from President
DoD
MedTeams®
ED Study
Institute for
Healthcare
Improvement
100K lives
Campaign
“To Err
is Human”
IOM Report TeamSTEPPS
1995 1999 2001 2003 2004 2005
JCAHO National
Patient Safety
Goals
MedicalTeamTraining

8. Impact of Error:
 44,000–98,000 annual deaths occur
as a result of errors
 Medical errors are the leading cause,
followed by surgical mistakes and
complications
 More Americans die from medical
errors than from breast cancer,AIDS,
or car accidents
 7% of hospital patients experience a
serious medication error
8
Cost associated with medical errors is $8–
29 billion annually.
Federal Action:
By 5 years;
 medical errors by
50%,
 nosocomial by 90%;
and
eliminate “never-
events” (such as wrong-
site surgery)

9. As many as 98,000 Americans still die each year
because of medical errors.
The researchers blame the:
 Complexity of Health Care Systems
Lack of Leadership
Reluctance of to admit Errors
Billing System that Reward Errors
9
05/18/2005
…little progress towards the goal
Leape and Berwick,
JAMA May 2005
Hospitals have taken steps to
reduce medical errors and
injuries.
Examples:
 Computerized prescriptions:
81% decrease in errors.
 Including pharmacist in
medical team: 78% decrease
in preventable drug
reactions.
 Team training in delivery of
babies: 50% decrease in
harmful outcomes — such as
brain damage — in
premature deliveries.
Source:Journal of the American
Medical Association
Improvements

10. 10

11.  Workload fluctuations
 Interruptions
 Fatigue
 Multi-tasking
 Failure to follow up
 Poor handoffs
 Ineffective
communication
 Not following protocol
11
 Excessive professional
courtesy
 Halo effect
 Hidden agenda
 Complacency
 High-risk phase
 Task (target) fixation

12. 12

13. “Initiative based on
evidence derived
from team
performance…lever
aging
more than 25 years
of research in
military, aviation,
nuclear power,
business and
industry…to acquire
team competencies”
13
Team Strategies &Tools to Enhance Performance & Patient Safety

14. 14
•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
inTeamwork, Human
Factors, and Crew
Resource Management
(CRM)

15.  Army aviation crew coordination
failures in mid-80s contributed to 147
aviation fatalities and cost more than
$290 million
 The vast majority involved
highly experienced aviators
 Failures were attributed largely
to crew communication,
workload management, and
task prioritization
15

16.  Cross-Training
 Stress ExposureTraining
 Team Coordination
Training (CRM)
 Scenario-BasedTraining and
Simulation
 Team LeaderTraining
 Team DimensionalTraining
 Team Assessment
16

17.  Mid to Late 80s AF bombers and
heavy aircraft started CRM training
 1992 Air Combat Command
developedAircrew Attention
Management /CRMTraining
 By 1998, CRM deployed uniformly
across the AF
 Steady decline in human factors
based mishaps since CRM training
deployed
 AF Medical Service adapted
training, rolled out in 2000
17

18. Non-Healthcare
• Combat Information
Centers
• Joint Forces Operations
• Army Special Forces
• Tank, Submarine, and Air
Crews
18
Team
Healthcare
ED, OR, L&D, ICU, Dental
Whole Hospital
Combat Casualty Care
…striving to be a high reliability healthcare system…

19. 19
Indemnity Experience
20
11
0
5
10
15
20
25
Malpractice Claims, Suits, and Observations
Pre-Teamwork Training Post-Teamwork Training
Adverse Outcomes
50%
Reduction
50%
Reduction
(Mann, 2006)
Beth Israel Deaconess Medical Center
Contemporary OB/GYN
1
1.2
1.4
1.6
1.8
2
2.2
2.4
June July August Sept Oct Nov Dec Jan Feb March April May
Avg.LengthofStay(days)
Length of ICU Stay After Team Training
50%
Reduction
OR Teamwork Climate and Postoperative Sepsis Rates
(per 1000 discharges)
Group Mean
Low Teamwork
Climate
Mid Teamwork
Climate
High Teamwork
Climate
0
2
4
6
8
10
12
14
16
18
AHRQ National Average
Teamwork Climate Based on Safety Attitudes Questionnaire
Low  High
(Sexton, 2006)
Johns Hopkins
(Pronovost, 2003)
Johns Hopkins
Journal of Critical Care Medicine

20. 50% reduction in adverse outcomes
Average length of ICU stay reduced by 50%
27% reduction in Nurse turnover
Decreased clinical error rate from 30.9% to
4%
Reduction by 50% in post-op sepsis rate

21.  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
 IntegrateTeamSTEPPS into daily practice.
21
“High-performance teams create a
safety net for your healthcare
organization as you promote a
culture of safety."
…Improved teamwork and
communications…
Ultimately, a culture of safety

22. 22

23. Knowledge
 Shared awareness about what is going on in theTeam and
progress towards its goals.Team members are familiar
with Roles and Responsibilities of theirTeammates
Attitudes
 Team members have a positive experience, enjoy working
in teams and trust intention ofTeam mates
Performance
 Team members know when and how to back each other
up, be more efficient in providing care, and more readily
identify and correct errors if they occur

24.  Knowledge
 Shared Mental Model
 Attitudes
 MutualTrust
 Team Orientation
 Performance
 Adaptability
 Accuracy
 Productivity
 Efficiency
 Safety
24

25. Mutual Support
Communication

26.  First step in implementing a teamwork system isTeam
Development
 Delineates fundamentals such as team size, membership,
leadership, identification and distribution
 Check the ratio of ‘WE’s to ‘I’s to assessTeam
Development
 Patients are part of the CareTeam
 Members anticipate needs of others, adjust to each
other’s actions and have a shared understanding of plan of
care

27. Team Leaders impact effectiveness by:
 changing behaviours
 motivating members
 coordinating processes
 facilitating problem-solving
 Leaders need to ensureTeams perform
effectively and attain desired outcomes
 Leaders monitor, diagnose and treatTeams
 Tools include brief, huddle, and debrief

28.  To gain or maintain an accurate awareness or
understanding of every situation in which the
team is functioning
 Results in a shared mental model among team
members
Elements include STEP:
 Situation of Patient
 Team Members
 Environment
 Progress towards Goals

29.  Also known as Back-up behaviour :allows
teams to become self-correcting, distribute
workload effectively and regularly provide
feedback
 Specific approach to conflict resolution
 Each team member becomes part of the
Safety Net

30.  Most important component ofTeam
Management.
 Standardized information exchange
strategies- SBAR, Check-back, Call-out,
Handoff, and Checklists
 Complete, Clear, Brief,Timely

31. 31
Catalytic event drives
need for change
Build team,
strategy, buy-in,
establish goals
Implement Action Plan,
Train, Empower Others
TeamSTEPPS
Change
Coaching
I’m staying
right here.
Yeah they’ll be
back.
What
are they
doing?
Why do
we need
change?
FUTURE
Celebrate wins!
Staying the course
Sustaining
Develop Action
Plan
Test
Intervention
(Outcomes)
Monitor, Integrate, Continuous
Process Improvement
Prepare
the Climate

32.  Advocates ofTeamwork
 Dynamic Presenters
 Viewed as Leaders amongst peers
 In positions that allow flexibility

33.  Fundamentals Course and Implementation Workshop for
Hospital Leadership and Steering Committee
 Assessing your Hospital in Patient Safety and Healthcare
Team Functioning
 Training your Healthcare Professionals inTeamSTEPPS
Strategies
 Developing your Quality Champions asTeamSTEPPS
Coaches
 Regular Assessment and Onsite Support
 Certify Hospitals asTeamSTEPPS Hospitals

34.  Competencies in Healthcare Project Management, Business
Development, Idea Generation, Process Improvement,
Financial Management and Healthcare Quality Management.
 MasterTrainers in TeamSTEPPS Patient Safety Strategies,
Certified by the US. Department of Defense and Agency for
Healthcare Research and Quality (AHRQ)
 Certified Project Managers with Project Management Institute
(PMI) in the United States.
 Certified Quality Management and Process Improvement Experts
with American Society of Quality (ASQ) .
 USAID SHOPS (Strengthening Health Outcomes though Private
Sector)Trainers on Financial Management for Medical Directors

35.  Only TeamSTEPPS Provider in Nigeria
 Hospital Quality Management and Process
Improvement
 Hospital Business Advisory and Financial
Management
 Tailored Capacity Development for Healthcare
Professionals
 Hospital Marketing and Branding Service
 Outsourced Hospital Management

36.  Phone- 08052064317, 08023277559
 Website- www.aesculapiusvn.com
 Facebook: Aesculapius Healthcare Consultants
 LinkedIn- Aesculapius VN
 Twitter- @AesHealthCon
 Email- aesculapiusvn@gmail.com,
 femi.aina@aesculapiusvn.com

37. ThankYou
Aesculapius Healthcare Consultants