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Create a platform for learning from defects


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Create a platform for learning from defects

  1. 1. “Create A Platform ForLearning From Defects”A CUSP ApproachKrish Sankaranarayanan MS, MBA, CPHQSenior Safety Officer- Tawam HospitalPresented at the2nd Annual Drug Safety MENA Summit13 - 14 February, 2013 - Radisson Blu Yas Island, Abu Dhabi, United Arab Emirates2013-4-17 1
  2. 2. Disclosure• The presenter has nothing to disclose, nor hasany commercial interest with any of thoseinformations displayed in this presentation.2013-4-17 2
  3. 3. About Tawam• Tawam Hospital is a 477-bed tertiary carefacility located in Al Ain, Abu Dhabi, and thelargest of the United Arab Emirates.• In 2006 Tawam Hospital entered a ten yearaffiliation with Johns Hopkins Medicine.2013-4-17 3
  4. 4. Items for discussion• Ice breaker- Eric Cropp a pharmacist, the errorthat sent him to prison (Video)• Second Victim• Culture of Safety• CUSP Approach- Tawam’s experience• Learning from defects• Celebrating Safety2013-4-17 4
  5. 5. Ice Breaker2013-4-17 5
  6. 6. Aftermath of an errorShame & Blame2013-4-17 6
  7. 7. Common Response After An Error• The types of suffering are– Increased anxiety about the future possibility oferrors,– Loss of confidence in the work they do,– Some face difficulty sleeping,– Concern about their reputation as a care giver– Reduction in their sense of job satisfaction.– Excellent clinicians may leave the professionprematurely when involved in a preventable error.
  8. 8. Medical error: the second victim..• The term second victim was initially coined by Wu in hisdescription of the impact of errors on professionals. Thedoctor who makes the mistake needs help too.• In the aftermath of a mistake, its important the doctor seeksupport to deal with the consequences.Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MD2013-4-17 8
  9. 9. • Middle East: There no or lack of statisticalevidence in this region to showcase patientdeaths happening due to medical error2013-4-17 9
  10. 10. This is what we see?2013-4-17 10
  11. 11. 2013-4-17 11
  12. 12. 2013-4-17 12
  13. 13. The patients saw an average of 17.8 healthprofessionals during their hospitalizationHow many health professionals does a patient see during an average hospitalstay? N Whitt, R Harvey, S Child2013-4-17 13
  14. 14. Building a Culture of Safety2013-4-17 14
  15. 15. Safety Culture in High ReliabilityOrganizations- HRO’s
  16. 16. Early adopters- Aviation
  17. 17. Definition• Safety culture is the ways in which safety is managed in theworkplace, and often reflects "the attitudes, beliefs, perceptionsand values that employees share in relation to safety" (Cox andCox, 1991).• The safety culture of an organization is the product of individualand group values, attitudes, perceptions, competencies, andpatterns of behavior that determine the commitment to, and thestyle and proficiency of, an organizations health and safetymanagement. Organizations with a positive safety culture arecharacterized by communications founded on mutual trust, byshared perceptions of the importance of safety, and by confidencein the efficacy of preventive measures. (AHRQ)• Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of NuclearInstallations) Study Group on Human Factors. Health and Safety Commission (of Great Britain).Sudbury, England: HSE Books, 1993.
  18. 18. Culture in safe organizations• Commit to no harm• Focus on systems not people• Value Communication/teamwork– Assertive communication– Teamwork– Situational awareness• Accept responsibility for systems in which wework• Recognize culture is local• Seek to expose (not hide) defects• Celebrate safety– Workers viewed as heroes2013-4-17 18
  19. 19. On February 22, 2001,eighteen-month old JosieKing died from medicalerrors at the JohnsHopkins Hospital19Peter J. Pronovost, MD, PhDis a practicing anesthesiologist andcritical care physician,teacher, researcher, andinternational patient safety leader.Johns Hopkins MedicineComprehensive Unit-based Safety Program(CUSP)
  20. 20. Johns Hopkins MedicineComprehensive Unit-based Safety Program(CUSP)CUSP is a 6-step safety programStep 1: Safety Attitude Questionnaire (SAQ)Step 2:Staff education on the Science of SafetyStep 3: 2-item Staff Safety Survey▪ Please describe how you think the next patient in your unit/clinical areawill be harmed?▪ Please describe what you think can be done to prevent or minimize thisharm?Step 4: Executive Walk RoundsStep 5:a) Learning from our mistakesb) Improve teamwork and communicationStep 6 : Resurvey staff about Safety Culture (annually)2013-4-17 20
  21. 21. How we started at Tawam?• January-08 Created the Patient Safety dept.recruited 4 patient safety officers and a medicationsafety officer.• February-08 Leadership training on Patient Safety• April-08 Comprehensive Unit based Safety ProgramRoll-Out.• 2008- ICU, NNU, Peds Onc (Pilot Units)• 2011- Medical 1 & 2, Surgical 1& 2, Daycase, PICU• 2012- OBGYN2013-4-17 21
  22. 22. CUSP in Ten Units2013-4-17 22
  23. 23. Challenges faced• Employees hail from 60 nations• Hierarchies between providers• A culture that isn’t accustomed toacknowledging medical errors.• Tendency for poor communication andteamwork that lead to adverse events.• Tawam had a history of, “you made amistake, and you’re terminated.”
  24. 24. CUSP is a leadership driven &Partnership driven program2013-4-17 24
  25. 25. Stakeholders & Team2013-4-17 25
  26. 26. “Insanity: doing the same thingover and over again andexpecting different results”Albert Einstein2013-4-17 26
  27. 27. “Every system is perfectly designedto achieve the results it gets.”Donald Berwick, M.D.2013-4-17 27
  28. 28. What can we do to improve?Errors can be prevented bydesigning systems that make ithard for people to do the wrongthing, and easy for people to dothe right thing.2013-4-17 28
  29. 29. Critical thinking!!!2013-4-17 29
  30. 30. System redesign2013-4-17 30
  31. 31. System Design- Forcing Function2013-4-17 31
  32. 32. Error Prevention2013-4-17 32• “Smart people learn from theirown mistakes, wise peoplelearn from others mistakes.”
  33. 33. Formula 1 Pit stop2013-4-17 33
  34. 34. Formula 1 Pit stop• Takes six to twelve seconds in duration.• Every pit stop is filmed and monitored byhuman factor experts• Errors are scored in five levels• Highest score goes to the smallest error,because people are unaware of it.2013-4-17 34
  35. 35. Aviation-Sterile cockpit rule• Prohibits crew member performance of non-essential duties or activities while the aircraft isinvolved in taxi, takeoff, landing, and all other flightoperations conducted below 10,000 feet, exceptcruise flight.• Prohibits the personal use of a personal wirelesscommunications device or laptop computer while aflight crew member is at duty station during allground operations2013-4-17 35
  36. 36. Learning from Defects- Tawam• Creation of Safety Event Analysis Teams ineach CUSP unit.– Identified a team of believers– Team identified defects from Patient Safety Net(PSN)– Implemented systems changes to reduce theprobability of recurring.– At least one defect was investigated each month.2013-4-17 36
  37. 37. System changes due to PSN’s onNarcotic medication error• Verbal order carried out against policy forNarcotic medication. (Fentanyl Patch)– Analyzed usage of each Narcotic and Controlledmedication (for the previous six months).– Determined Critical/emergency need of each n drug.– List of Narcotic and Controlled medications werereduced to half.– ICU physicians and nurses informed about thechanges.– Review the usage every 3 months.2013-4-17 37
  38. 38. Team members involved beingfelicitatedIn the picture:Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna2013-4-17 38
  39. 39. When errors occurThree things happen• It can cause people to become championsOr• It can cause people to leave the professionprematurelyOr• It can make people go in to a shell andcompletely feel withdrawn- Disengaged.2013-4-17 39
  40. 40. Medication Error Story-1Double check forexpiration date notdone properlyFirst Nurse proceededto administer thevaccine without takingthe tablet PC to thepatient bed sideVaccine Injected andasked second Nurse tochart in Cerner on hisbehalfSecond Nurse baffled after seeingthe expiration date and themissing expiration date in thelabelError reachedthe patient butdid not causeharmExpired vaccinearrived fromPharmacySWISS CHEESE MODEL 402013-4-17
  41. 41. Medication Error Story-2ChemotherapyWritten by MD.VincristinedoxorubicinAndl_aspargenesCheckedaccordingTo the protocolThen faxedto pharmacyPrepared byPharmacyMedicationReceived fromPharmacy,Checked withAnotherChemotherapyCompetentNurseVCRDOXOL-AspTwo medicationtaken topatient roomVCRandDOXOAndEmla creamL-Asp returned tofridge412013-4-17
  42. 42. Medication Error Story-3WhatHappened• Remicade a non formulary was administered to the patient (order wasin paper)• Premedication of antihistamine, panadol was ordered in CERNERwhich was not communicated to the nurse• The patient developed allergic reactionsWhat Next• Investigation revealed that there was no set protocols or guidelines• Break down in communication & information transferAction• Guidelines, protocols and checklist were developed• No incidents since then2013-4-17 42
  43. 43. Implication of the errors• The staff came open and reported theincidents• Since CUSP was in place it helped institute aFair and Just Culture• Investigation of the incidents, examined theprocesses and not just people.• The three nurses have now become advocatesof patient safety by sharing their experiences.432013-4-17
  44. 44. Distribution of Harmful Events by CareUnits, 20100 20 40 60 80 100 120 140 160 180 200Medical 1Naima PharmacyORPaeds MedicalMedical 2Paeds Oncology1131281391521631831302910113No. Harmful eventNo. of Reported Event2013-4-17 44
  45. 45. Medication Error Story-4(Second Victim)• A nurse inadvertently administered a chemotherapy drug to a wrongpatient. The patient was ok and the error was openly disclosed to thefamily. It was a clear case of the nurse not adhering to the five sevenprinciple and independently double checking the high alert medication. Acase of negligence!!!The nurse had no previous history of such an error was emotionally sodistressed that the nurse could no more work in the unit. The patientfamily members did realize that the error was not intentional and didsupport the nurse who was devastated due to the incident.Despite the fact that culture of safety program was existence in the unitfor over four years, there was no established mechanism to console thenurse. Due to the increased anxiety about the future possibility of errorsand loss of confidence in ones own work, tragically the nurse chose toleave the specialty prematurely, the one that the nurse had been workingfor over fifteen years.2013-4-17 45
  46. 46. PSN -Data2013-4-17 460.0%20.0%40.0%60.0%80.0%100.0%2011 201266.7% 63.1%26.6% 31.6%6.7% 5.3%%ReportedMedicationRelatedEventsEvent Reached the Patient with harm Event Reached the Patient with no harm Near Miss
  47. 47. Medication Error Rate2011 2012Medication Error Rateper 10,000 dispensed Items 2.3 1.8
  48. 48. Celebrating Safety – Viewing workersas heroes• Best Catch Award 2009• Best Catch Award 2010• Best Catch Award 2011• Best Catch Award 20122013-4-17 48
  49. 49. • To improve reporting and learn from mistakes.• To enhance the culture of safety.• To put focus on processes and at-riskbehaviors, not just on outcomes• To recognize staff for their contribution toquality and patient safety.• To proactively identify and implement riskreduction strategiesObjectives2013-4-17 49
  50. 50. Patient Safety Net (PSN)PSN- Harm Score 1 & 2 (Near Misses)Data source2013-4-17 50
  51. 51. • Number of people that could be affected.• The likelihood of Occurrence• Severity: The impact(s) of failure• Detectability• Followed with a systemic corrective actions orplan.Criteria for selection2013-4-17 51
  52. 52. • Preliminary screening/selection was done bythe department heads.• Short list Near Misses were submitted toSenior Leadership Committee for finalselection.Methodology2013-4-17 52
  53. 53. Best Catch Award 2009Synopsis :• Physician placed an order through HIS for patient for paracetamol 1000 mg POPRN Q6H for pain/fever was inadvertently documented as 10,000 mg. Thepharmacy verified this order as such. Nursing caught the error, and called to havethe order modified to paracetamol 1,000 mg PO PRN Q6H for pain/fever.2013-4-17 53Ahlem Hussein RN &Sharif Deeb Qandil pharmacistPrevented high dose ofpain medication
  54. 54. Best Catch Award 201054Synopsis :Chemotherapy IFOSFAMIDE per protocol is for four doses, and it was written for 5 days.The fifth dose arrived , nurse checked protocol and prevented.Systemic change :A copy of the protocol in pharmacy and patient chart to double check and prevent errors.2013-4-17Prevented excess dose ofChemotherapy medication
  55. 55. Best Catch Award 2011Synopsis :Rubella vaccine was ordered. The dose was delivered, clearly in a vial which stated single dose. In otherwords, the whole vial was a single dose, all of which should be diluted and administered. The pharmacy sentthe dose with a special blue label which called for the nurse to pay attention to the specific dose. The nursecalled to try to understand what was the actual dose. The pharmacist told her she should only give 1/10th ofthe vial, once reconstituted. Dr. Jenny who happened to be watching and inspecting the bag with the vaccinethought this was not right. She called the pharmacy again and this time the pharmacist double checked thevaccine changed the recommendation to administer the whole vial. If the nurse had given 1/10 of the dose,the patient would not have been properly immunized.2013-4-17 55Prevented improperimmunization
  56. 56. Synopsis :The pharmacist received a medication refill order from a doctor for a pediatric patient andnoted a mismatch between the refill order and the current medication that the patient wastaking. She contacted the doctor and the child’s mother, verified the medication and correctedthem in the order.2013-4-17 56Best Catch Award 2011Prevented wrong refill orderof medication
  57. 57. Best Catch Award 2011SynopsisThe physician had ordered Metototrexate IT for this patient. In OR the mother of thepatient told the nurse that the patient should receive Cytarabin IT, not Metotrexate. ThePhysician had prescribed the wrong drug.2013-4-17 57Prevented administration ofwrong chemotherapy medication
  58. 58. Discussion-The End Game2013-4-17 58
  59. 59. Healthcare Needs Robust System• A cooperative effort between governmentagencies (regulatory authorities), Health Policymakers and industry to lead improvements insafety.• Healthcare needs an independent bodymodeled after the National Transportationand Safety Board (NTSB). 59
  60. 60. For hospitals to become safer• Hospital Leaders must say that they will doaway with errors.• Hospital Leaders must realize that an eventthat occurred in another organization couldone day happen in their hospital.2013-4-17 60
  61. 61. Positive thing• UAE-– SEHA one of the largest healthcare systems in the regionhas established the PSN reporting tool in all its businessentities.– DHA Implements New Patient Safety System called “Aman”based on a global healthcare safety system called DATIX• KSA- Is now asking all hospitals, government orprivate, to use online reporting for any seriousmedical error.• Qatar- HMC has introduced real time incidentreporting system at its chain of hospitals.2013-4-17 61
  62. 62. Resources-websites••••••••••• www.emilyjerryfoundation.org2013-4-17 62
  63. 63. References• Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System.Washington: National Academy Press; 1999• Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarkingdata, and emerging research. BMC Health Serv Res 6(44):Apr. 3, 2006.• Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm JQual and Saf 2006 32(2):102-8.• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to EnhanceNurse Leaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.• Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the ComprehensiveUnit-Based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J QualPatient Saf 2010;36(6):252-260.• Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicingphysicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467–76• Rossheim J. To err is human—even for medical workers. Healthcare monster. (accessed 21 Jan 2009).• Wu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs helptoo". BMJ 320 (7237): 726–7.• How many health professionals does a patient see during an average hospital stay? N Whitt, RHarvey, S Child• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to EnhanceNurse Leaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.2013-4-17 63
  64. 64. Culture of Safety is a journey• It takes as long as 5 years to develop a cultureof safety that is felt throughout anorganization. (Ginsburg 2005)• Need Patience, Perseverance, Commitment &Engagement.2013-4-17 64
  65. 65. 2 question survey• Please describe how you think the nextpatient in your unit/clinical area will beharmed.• Please describe what you think can be done toprevent or minimize this harm.2013-4-17 65
  66. 66. Thank YouPatient Safety Top PriorityPatient Safety Everyones ResponsibilityContacts:ksankara@tawamhospital.ae050-92116492013-4-17 66