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18 months with SPS reducing harm
- 2. Our first 18 months with SPS Trey Coffey CAPHC Patient Safety Symposium Oct 22, 2016 @trey_coffey_TO #caringsafely
- 4. Four Objectives of Caring Safely* 1. Reduce the incidence of Serious Safety Events (SSEs) by two-thirds 2. Improve Staff Safety by reducing lost time injury count, frequency rate and/or severity by 20% 3. Reduce the incidence of the seven Hospital Acquired Conditions (HACs) significantly 4. Enhance our Safety Culture by adhering to the principles of High Reliability Organizations * April 2015 – March 2018
- 5. Taking on all patient and staff harms simultaneously •Central line infections •Surgical site infections •Pressure Injuries •Catheter-associated Urinary tract Infection •Ventilator associated pneumonia •Falls with significant harm •(Adverse Drug Events) Bundle reliability: Set teach audit the standard • Delayed recognition/response to deterioration, e.g. sepsis • Failure to respond to results of investigations • Errors in decision-making • Failure to use expertise High Reliability Culture: Error prevention strategies Leadership methods RCA System redesign 16
- 6. Hospital Acquired Condition Network Center Line SickKids Center Line Adverse Drug Event 0.03/1000 pt days Catheter Associated Urinary Tract Infections 1.35/1000 catheter days Central Line Associated Blood Stream Infections 1.52/1000 line days Falls (Moderate or Greater Injury) 0.02/1000 pt days Pressure Injuries (formerly ulcers) 0.11/1000 pt days Surgical Site Infections 1.71/100 procedures Ventilator Associated Pneumonia 0.54/1000 vent days Benchmarking against Network data helps to identify priorities of focus and accomplishments to celebrate and sustain
- 7. Culture Work
- 9. Too easy to hide lack of progress
- 10. HOW CAN WE PREVENT THIS?SUMMARY OF EVENT Capturing Events The Case of the: <title> <Date> WHY DID THIS EVENT HAPPEN? The story presented above is an example of patient safety events occurring in hospitals across the country. As a learning organization, telling these stories is intended to generate dialogue among frontline caregivers who may be able to prevent a similar occurrence. For internal use only. HOW CAN WE SUPPORT THE CULTURE OF SAFETY?
- 11. Caring Safely: Error Prevention Education
- 12. Caring Safely Trainers Trained to Date EP = 2609/8000 LM = 375/700
- 14. ‘We’re not going to compete on safety’: Canadian paediatric health centres collaborate on journey to eliminating preventable harm Clinical and operational leaders from SickKids, CHEO, and IWK came together to share ideas and key learnings about the journey to reducing preventable harm.
- 15. getting the message out https://youtu.be/lS-imG76Nv0
- 17. Serious Safety Event: Event involving a deviation from Generally Accepted Practice Standard causing moderate to severe harm © 2006, HPI, LLC Precursor event: Event that DID reach patient but resulted in minimal or temporary harm. Near Miss: Event that almost happened, but error was caught Critical Incident Serious Patient Safety Incident 12
Editor's Notes
- Time: 1 min
- SPS is the only HEN to focus not just on HACs but also on SSEs
- Error Prevention- The interactive session sets the stage for understanding how errors occur and discusses the error prevention strategies to be adopted in order to meet the expected behaviors for Caring Safely. These practical strategies are aligned with high reliability organization principles, and audience participation is encouraged in the exercises to develop insight, confidence and competence in enacting these strategies for error prevention. ARCC QVV Stop & Resolve STAR Leadership Methods- Learn, adopt and practice leadership skills for building and sustaining a culture of safety and performance excellence. The role then of leaders at all levels is to effectively influence behaviors to achieve performance expectation. Rounding to Influence Safety Huddles Organizational Safety Brief Top 10 Problem List Safety Coach Program- Safety coach program is a tool for reinforcing the safety training techniques for a sustainable safety culture. Observe the performance of a group or individuals to determine if practice meets our Safe Behavior expectations Provide real time feedback to reinforce good practices and correct unsafe practices
- Time: 1 min Key Point: Introduction to trainers. Introduce yourself as the trainers for today’s session., and that you are a part of a team of 54 Caring Safely trainers for the hospital. My name is……, and I work …..
- Definitions in our Management of Serious Patient Safety Incidents policy Critical incident (relates to Public Hospitals Act): “Any unintended event that occurs when a patient receives treatment in the Hospital that results in a) death or serious disability, injury, or harm and b) does not result primarily from the patient’s underlying medical condition or from a known risk inherent in providing treatment” (this leaves a lot of discretion to the hospital - policy states that decision is made by Risk, with Chief, EVP Clinical, VP Medical, and Clinical Director if applicable – practical experience is that Risk has most influence on what is called) Serious Patient Safety Incident (relates to Canadian Incident Analysis Framework) “an event or circumstance which could have resulted or did result in severe unnecessary harm to a patient, including death and permanent loss of function, that does not result primarily from the patient’s underlying condition” Main difference between these and SSE is that these require severe/permanent loss of function Serious Safety Events are deviations in best-practice care that result in: Death Severe permanent harm Moderate permanent harm Severe temporary harm: Detectable harm, lasting for a limited time only, resulting in no permanent injury, yet causing great discomfort, injury, and/or distress. For example, resuscitation required or additional procedure/surgery. Precursor Events Near-Miss Events