Science of Safety TrainingPresented by Krish Sankaranarayanan MS, MBA, CPHQ Senior Safety Officer 2013-4-17 1
Introduction-About me• Been in healthcare domain for over 24 years.• Triple Masters degree.• MS in Patient Safety Leadership from UOI- Chicago.• Certified Professional in Healthcare Quality (CPHQ)• Educational consultant- Canadian Healthcare Association- CQI program• Membership – Member American College of Healthcare Executives – Member National Association of Healthcare Quality – Member American Society for Healthcare Risk Management – Member American Society of Professionals in Patient Safety – Vice President of the ACHE Middle East and North Africa Group
Discussion Items• Ice Breaker- Eric Cropp story (Video)• Historical context of Patient Safety?• Second Victim• Comprehensive Unit-based Patient Safety program- Josie King Story (Video)• Learning from defects• Celebrating Safety• 2-Question Survey2013-4-17 3
Medical error: the second victim.. • The term second victim was initially coined by Wu in his description of the impact of errors on professionals. The doctor who makes the mistake needs help too. • In the aftermath of a mistake, its important the doctor seek support to deal with the consequences.Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MD 2013-4-17 6
The Annual Toll of Medical Injury IOM “To Err is Human” (1999)• 44,000 – 98,000 deaths/year in US due to medical errors.• $ 50 billion in total costs.• 7% of patients suffer a medication error.• Every patient admitted to ICU suffers an adverse event.
Definition• Safety culture is the ways in which safety is managed in the workplace, and often reflects "the attitudes, beliefs, perceptions and values that employees share in relation to safety" (Cox and Cox, 1991).• The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organizations health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. (AHRQ)• Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.
Safety Culture in High ReliabilityOrganizations- HRO’s
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 we work• Recognize culture is local• Seek to expose (not hide) defects• Celebrate safety – Workers viewed as heroes2013-4-17 23
Johns Hopkins Comprehensive 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 area will be harmed? ▪ Please describe what you think can be done to prevent or minimize this harm?Step 4: Executive Walk RoundsStep 5:a) Learning from our mistakesb) Improve teamwork and communicationStep 6 : Resurvey staff about Safety Culture (annually)
How we started at Tawam?• January-08 Created the Patient Safety dept. recruited 4 patient safety officers and a medication safety officer.• February-08 Leadership training on Patient Safety• April-08 Comprehensive Unit based Safety Program Roll-Out. • 2008- ICU, NNU, Peds Onc (Pilot Units) • 2011- Medical 1 & 2, Surgical 1& 2, Daycase, PICU • 2012- OBGYN • 2013- OR & ED2013-4-17 25
Greatest Challenge at Tawam • Employees hail from 60 nations • Hierarchies between providers • A culture that isn’t accustomed to acknowledging medical errors. • Tendency for poor communication and teamwork that lead to adverse events. Tawam had a history-“you made a mistake, and you’re terminated.”
Measuring Culture of Safety tested and well known tools• Safety Attitudes Questionnaire• Patient Safety Culture in Healthcare Organizations• Hospital Survey on Patient Safety Culture• Safety Climate Survey• Manchester Patient Safety Assessment Framework
Baseline assessment-Safety Attitudes Questionnaire Culture of Safety Survey- Domains 1.Teamwork Climate 2.Safety Climate 3.Job Satisfaction 4.Stress Recognition 5.Working Conditions 6.Perceptions of Hospital Management 7.Perceptions of Unit Management 28
Dependent Variables of SAQ • The primary dependent variables -teamwork climate and safety climate scale scores. • These primary dependent variables were chosen because they are important in preventing patient harm. • The rest of them are secondary dependent variables.Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res6(44):Apr. 3, 2006.Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-Based Safety Program (CUSP) on safetyculture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36(6):252-260.
Safety Attitude Questionnaire-(SAQ) Survey Targeted Surveys Survey response Location Year staff Administered Returned ratePhase 1 CUSP Pilot Units 2008 199 199 199 100%Phase 2 In-patient areas 2010 1600 1476 1450 98% Out-Patient & satellite Qtr 4Phase 3 locations 2011 805 497 483 60% Total 2604 2172 2132 82% of staff in patient care areas have participated in the overall 3 phases of SAQ Survey. 81% overall response rate in all the 3 phases of SAQ Survey.
2008 SAQ Phase-1 (CUSP Pilot Units) SAQ Results 2008 100% 80%Average % Positive 60% ICU 40% Pediatric Oncology NNU 20% 0% Teamwork Safety Job Stress Perceptions Perceptions Working Satisfaction Recognition of Hospital of Unit Conditions Management Management Domain
2010 SAQ Phase-2(All In-patient Units- & CUSP Pilot Units Re-survey)
2 question survey: CUSP Expansion Pilot Units- 2008 • Please describe how you think the next patient in your unit/clinical area will be harmed. • Please describe what you think can be done to prevent or minimize this harm. 2-item Staff Safety Survey30%25%20%15% ICU N=93 NICU N=7310% Peds Onc N=395%0% Communication Staffing Medication Infection Policies & Education Equipment Others & Teamwork Errors Control Procedures Areas of concern
2 question survey: CUSP Expanded Units- 2010 & 11 • Please describe how you think the next patient in your unit/clinical area will be harmed. • Please describe what you think can be done to prevent or minimize this harm. 2-Question survey OtherEquipment/Environment/facilities Education ObgynPolicies/Procedures and systems Surg 2 Surg 1 Infection Control Daycase Medication Errors Med 2 Med 1 Staffing Communication/Teamwork 0% 10% 20% 30% 40% 50% 60%
“I Watch The Line”- Campaign• To increase staff awareness• To ensure staff active involvement• To ensure conscientious implementation ICU NNU PICU 44
CLABSI Free Days• ICU – 323 CLABSI free days until 25th Dec 2012 – Recounting -42 CLABSI free days until 5th February. – Recounting -23 CLABSI free days until 28th Feb.• NNU-183 days until 28th Feb.• PICU- 115 days until 28th Feb. 45
“Insanity: doing the same thing over and over again and expecting different results” Albert Einstein2013-4-17 46
“Every system is perfectly designed to achieve the results it gets.” Donald Berwick, M.D.2013-4-17 47
Formula 1 Pit stop• Takes six to twelve seconds in duration.• Every pit stop is filmed and monitored by human factor experts• Errors are scored in five levels• Highest score goes to the smallest error, because people are unaware of it.2013-4-17 55
Aviation-Sterile cockpit rule• Prohibits crew member performance of non- essential duties or activities while the aircraft is involved in taxi, takeoff, landing, and all other flight operations conducted below 10,000 feet, except cruise flight.• Prohibits the personal use of a personal wireless communications device or laptop computer while a flight crew member is at duty station during all ground operations2013-4-17 56
When errors occur one of the three things happen• It can cause the person to become a championOr• It can cause the person to leave the profession prematurelyOr• It can make the person go in to a shell and feel completely withdrawn and Disengaged.2013-4-17 57
Medication Error Story-1 First Nurse proceeded to administer the vaccine without taking Second Nurse baffled after seeing the tablet PC to the the expiration date and the patient bed side missing expiration date in the Expired vaccine label arrived from Pharmacy Error reached Double check for the patient but expiration date not did not cause done properly harm Vaccine Injected and asked second Nurse to chart in Cerner on his behalfSWISS CHEESE MODEL 2013-4-17 58
Medication Error Story-2ChemotherapyWritten by MD. Checked Vincristine according Prepared by doxorubicin To the protocol Pharmacy And Then faxed Medication l_aspargenes to pharmacy Received from Pharmacy, Checked with AnotherTwo medication Chemotherapy taken to Competent patient room Nurse VCR VCR and DOXO L-Asp returned to DOXO L-Asp fridge And Emla cream 2013-4-17 59
Medication Error Story-3 • Remicade a non formulary was administered to the patient (order was in paper) • Premedication of antihistamine, panadol was ordered in CERNER What which was not communicated to the nurseHappened • The patient developed allergic reactions • Investigation revealed that there was no set protocols or guidelines • Break down in communication & information transferWhat Next • Guidelines, protocols and checklist were developed • No incidents since then Action2013-4-17 60
Implication of the errors • The staff came open and reported the incidents • Since CUSP was in place it helped institute a Fair and Just Culture • Investigation of the incidents, examined the processes and not just people. • The three nurses shared their experiences with other CUSP units. • The three nurses have now become our patient safety champions.Broke the myth-“you made a mistake, and don’t get terminated.” 2013-4-17 61
Learning from Defects- Tawam• Creation of Safety Event Analysis Teams in each CUSP unit. – Identified a team of believers – Team identified defects from Patient Safety Net (PSN) – Implemented systems changes to reduce the probability of recurring. – At least one defect was investigated each month.2013-4-17 62
Impact of CUSP on the staffCUSP Can turn ordinary people in to champions 63
Best Catch Award programCelebrating Safety – Viewing workers asheroes• Instituted in 2009 for the best near miss caught.• Now in the fourth year of implementation.• Provided opportunity for staff to proactively identify and implement risk reduction strategies.• 2010, 2011 & 2012 Best Catch awards went to CUSP units.
Best Catch Award 2010 Pediatric Oncology- CUSP Prevented excess dose of Chemotherapy medicationSynopsis :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. 2013-4-17 65
Best Catch Award 2011 ICU- CUSP Rhian Evans Associate Nurse Manager – ICU receives the award from the CEO Mr. Gregory Schaffer Prevented cauterization and accidental fire in the ICUSynopsis :Cauterization (ritualistic burning) Prevented family from approaching patient onventilator with hot burning coal in patient room. Coal was extinguished safely.Resulted in system and policy changes.
Best Catch Award 2011 NNUCUSP Asuncion Carlos Sr. Respiratory Therapist - receives the award from the CEO Mr. Gregory Schaffer Prevented inappropriate order for therapySynopsis :An inappropriate order for heliox therapy for NNU patient was not carried out.2013-4-17 67
Best Catch Award 2012Peds Oncology CUSP Prevented administration of wrong chemotherapy medication Synopsis The physician had ordered Metototrexate IT for this patient. In OR the mother of the patient told the nurse that the patient should receive Cytarabin IT, not Metotrexate. The Physician had prescribed the wrong drug. 2013-4-17 68
Arab Health Awards• Tawam’s patient safety initiatives were shortlisted for Arab Health in 2010 and 2011 awards and bestowed “commendable.”
Dr. Prathap C Reddy’s Safe CareAwards 2011 India –Judging Panel Dr Pranav Mehta VP Physician & Ambulatory Care Services, North Shore Long Island Jewish Healthcare System & Examiner of prestigious National Malcolm Baldrige Quality Award Ms. Diane C. Pinakiewicz President-National Patient Safety Foundation Ms. Manisha Shah VP -National Patient Safety Foundation Ms Ann Jacobson Executive Director International Accreditation, JCIA Dr Cyrus Engineer Manager, WHO Patient Safety project, Johns Hopkins
Award being received from the Chief Minister of the Indian State of Andhra PradeshAwarded to Tawam Hospital for the project title- Establishing “Culture of Safety”-A UAE HospitalExperienceHis Excellency Nallari Kiran Kumar Reddy, Honble Chief Minister of Andhra Pradesh standingfourth from left, gives away the award. Also present Diane C. Pinakiewicz President NPSF and DrPrathap C Reddy, M.D, MBBS, FCCP, FICA, FRCS Apollo Hospital Group India
Presented in conferences1. Speaker at the Patient Safety Congress–IIRME Abu Dhabi- October 2009.2. Speaker at the ICHA Convention for Patient Safety -New Delhi India- October 20093. Speaker at the Healthcare Management Forum -IIRME Dubai- January 2010.4. Submitted poster at the International Forum on Quality and Safety in Healthcare at Nice-April 2010.5. Submitted poster at the Patient Safety Congress in UK-May 2010.6. Speaker at the Quality Standards and Accreditation Conference at Dubai -June 2010.7. Presented poster at the 13th International Conference on Emergency Medicine at Singapore-June 2010.8. Speaker at the Safety 2010 World Conference at UK- September 2010.9. Speaker at the Patient Safety Congress–IIRME Abu Dhabi-October 2010.10. Speaker at the International Patient Safety Conference-AIIMS New Delhi-October 2010.11. Speaker at the Healthcare Management Forum -IIRME Dubai- January 2011.12. Speaker at the First International Conference on Patient Safety -Oman-February 2011.13. Speaker at the KFSHD -Quality and Safety Event –Saudi Arabia-April -2011.14. Speaker at the Patient Safety Congress- Best Practices for Asia- India-April 2011.15. Speaker & Organizer of 2nd Tawam’s Patient Safety Conference- Al Ain- June 2011.16. Speaker at the at the XIX World Congress on Safety and Health at Work- Turkey- Sep 2011.17. Speaker at the 3rd Johns Hopkins Medicine Annual Patient Safety Summit- Baltimore USA- June 201218. Speaker by Tel-Conference at the URMPM WORLD CONGRESS -UK, Sep 2012.19. Presented poster at the 5th Medication Safety Conference-Abu Dhabi-Nov 2012.20. Speaker at the 2nd Drug Safety MENA Summit-Abu Dhabi-February 2013.21. Member Scientific Advisory Board and Speaker at the Patient Safety & Quality Congress Middle East- Abu Dhabi- March 201322. Speaker at The 15th Annual NPSF Patient Safety Congress- USA- May 20132013-4-17 72
Culture of Safety is a journey• It takes as long as 5 years to develop a culture of safety that is felt throughout an organization. (Ginsburg et.al 2005)• Need Patience, Perseverance, Commitment & Engagement.2013-4-17 73
2-question Survey• Please describe how you think the next patient in your unit/clinical area will be harmed?• Please describe what you think can be done to prevent or minimize this harm?2013-4-17 75