What Is Possible In A Hospital?
Getting To Zero Harm
Cincinnati Children’s Story
November 4, 2013
Stephen E. Muething, MD
...
SET THE GOAL
ACCEPT THE GAP
CONTINUOUS IMPROVEMENT
Our Safety Goal:
ELIMINATE ALL HARM
Begin With Serious Harm
Serious
Safety
Events
Serious Preventable
Events
Events of Minimal
to Moderate Harm
Near-Miss Events
Pyramid
of Harm
Began
Situation Awareness
High Reliability Organizations (HROs)
Kathleen M. Sutcliffe, MSN, PhD
Karl E. Weick, PhD
High Reliability Organizations
En...
Characteristics of
High Reliability Organizations
1. Preoccupation with failure
Regarding small, inconsequential errors as...
Serious
Safety
Events
Serious Preventable
Events
Events of Minimal
to Moderate Harm
Near-Miss Events
Pyramid
of Harm
75% Reduction
80% Reduction
0
2
4
6
8
10 07-052600
09-052433
11-052254
01-062002
03-061734
05-061983
07-062332
09-062355
11-062432
01-072330
03-072604...
HIGH
RELIABILITY
CULTURE
Pre-Surgery Time-Out
Huddles
Increase Reporting
Empowering to Stop the Line
Frontline Leaders Owning Harm
Peer
Observation
THANK YOU!
QUESTIONS?
stephen.muething@cchmc.org
http://www.cincinnatichildrens.org/research/divisions/j/anderson-center/d...
What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um Hospital Alcançar Meta d...
What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um Hospital Alcançar Meta d...
What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um Hospital Alcançar Meta d...
What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um Hospital Alcançar Meta d...
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What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um Hospital Alcançar Meta de Dano Zero? A História do Cincinati Children's Hospital)

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Apresentação de Stephen Muething durante o SIMPÓSIO EINSTEIN-IHI: Implantação e Disseminação de Programas de Segurança do Paciente aconteceu de 3 a 5 de novembro de 2013, em São Paulo - Brasil.

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What is possible in a hospital getting to zero harm cincinati childrens story (É Possível para Um Hospital Alcançar Meta de Dano Zero? A História do Cincinati Children's Hospital)

  1. 1. What Is Possible In A Hospital? Getting To Zero Harm Cincinnati Children’s Story November 4, 2013 Stephen E. Muething, MD Vice President for Safety James M. Anderson Center
  2. 2. SET THE GOAL ACCEPT THE GAP CONTINUOUS IMPROVEMENT
  3. 3. Our Safety Goal: ELIMINATE ALL HARM Begin With Serious Harm
  4. 4. Serious Safety Events Serious Preventable Events Events of Minimal to Moderate Harm Near-Miss Events Pyramid of Harm
  5. 5. Began Situation Awareness
  6. 6. High Reliability Organizations (HROs) Kathleen M. Sutcliffe, MSN, PhD Karl E. Weick, PhD High Reliability Organizations Environment rich with potential for errors Unforgiving social and political environment Learning through experimentation difficult Complex processes Complex technology
  7. 7. Characteristics of High Reliability Organizations 1. Preoccupation with failure Regarding small, inconsequential errors as a symptom that something is wrong; finding the half-event 2. Sensitivity to operations Paying attention to what’s happening on the front-line 3. Reluctance to simplify Encouraging diversity in experience, perspective, and opinion 4. Commitment to resilience Developing capabilities to detect, contain, and bounce-back from events that do occur 5. Deference to expertise Pushing decision making down and around to the person with the most related knowledge and expertise
  8. 8. Serious Safety Events Serious Preventable Events Events of Minimal to Moderate Harm Near-Miss Events Pyramid of Harm
  9. 9. 75% Reduction
  10. 10. 80% Reduction
  11. 11. 0 2 4 6 8 10 07-052600 09-052433 11-052254 01-062002 03-061734 05-061983 07-062332 09-062355 11-062432 01-072330 03-072604 05-072556 07-073207 09-072603 11-072574 01-082464 03-082224 05-082792 07-082786 09-082447 11-082335 01-092667 03-092835 05-092370 07-092924 09-092625 11-092514 01-102421 03-103045 05-102892 07-103214 09-102790 11-102741 01-112871 03-113111 05-113274 07-113756 09-113552 11-113583 01-123444 03-123695 05-123994 07-124283 09-123504 11-123674 01-133462 Infectionsper100ProcedureDays Month of Procedure Procedure Days Infections Surgical Site Infections by Procedure Date (Class I & Class II Combined) Last Updated 02/14/2013 by K. Simon, Anderson Center for Health Systems Excellence Source: Surgical Safety Database Q2/05 - Individual Anesthesia Follow-up Q3/05 - Anesth Compensation tied to compliance Q3/05 - Orange ID Bracelets Q4/05 - ABX In-pt Implementation Q2/06 - CHG Wipes by All Services Q3/06 - Bundle Measure for Limited Ortho & Neuro Desired Direction of Change 40% Reduction
  12. 12. HIGH RELIABILITY CULTURE
  13. 13. Pre-Surgery Time-Out
  14. 14. Huddles
  15. 15. Increase Reporting
  16. 16. Empowering to Stop the Line
  17. 17. Frontline Leaders Owning Harm
  18. 18. Peer Observation
  19. 19. THANK YOU! QUESTIONS? stephen.muething@cchmc.org http://www.cincinnatichildrens.org/research/divisions/j/anderson-center/default/

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