In 3 sentences:
The document discusses patient safety in the VA system and why focusing on patient safety is important. It provides statistics on the size of the VA system and notes that medical errors harm millions of people each year, costing billions of dollars. The document advocates using a systems approach and human factors engineering to improve patient safety, rather than just policies or individual blame, in order to have the biggest impact on preventing future harm.
Patient Safety Initiatives Maloy IDN Summit Fall 2009Dan Maloy
Fall 2009 IDN Summit presentation on Patient Safety Initiatives and their importance to healthcare product suppliers; includes a discussion of healthcare "Never Events" and product value proposition development
Patient Safety Initiatives Maloy IDN Summit Fall 2009Dan Maloy
Fall 2009 IDN Summit presentation on Patient Safety Initiatives and their importance to healthcare product suppliers; includes a discussion of healthcare "Never Events" and product value proposition development
Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.
ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.
Please send your email address to info [at] anesthesiallc [dot] com if you would like to join the Communique mailing list!
Visit www.anesthesiallc.com for more information!
Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.
ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.
Please send your email address to info [at] anesthesiallc [dot] com if you would like to join the Communique mailing list!
Visit www.anesthesiallc.com for more information!
In this presentation from the Beryl Institute's 2016 Patient Experience Conference, Edwards-Elmhurst Healthcare’s ED Chair and Patient Experience Director detail how they are leveraging technology to follow up with ED Patients and the exceptional results they’ve enjoyed.
Medical errors are ubiquitous and the costs (human and financial) are substantial. The top priority must be to redesign systems geared to prevent, detect and minimise effects of undesirable combinations of design, performance, and circumstance.
Presentation given at the Sidney R Garfield Center for Health Care Innovation, with other colleagues, on the potential for integrating social media into an integrated care system.
Orthopaedic Care Shifts to Outpatient and Urgent Care ClinicsApril Bright
The Shift in Care Delivery - As the healthcare delivery system evolves, hospitals may no longer be the first stop for patients seeking orthopaedic care. This is evidenced by the growing trend of surgeons moving to the outpatient setting, as patients seek less invasive procedures. Orthopaedic urgent care centers have also emerged as a viable alternative, due to their ability to address price concerns in the industry by reducing time and overhead costs for both providers and patients.
Attendees gain more insight into this shift, and learn how it will affect demands on manufacturers from a product design and delivery standpoint.
The De-Identification of a Large Electronic Medical Records Database for Seco...Luk Arbuckle
Over the last decade Canada has seen extensive reforms, investments, and innovations in primary health care. The Canadian Working Group for Primary Healthcare Improvement recommended that performance reporting be a strategic priority in moving towards transforming the primary health care system. To enable scalable and sustainable performance measurement and reporting, automated data collection from electronic medical records (EMR) will be necessary. EMR data can also play an important role in adverse drug event detection and public health surveillance.
Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.
ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.
Please send your email address to info [at] anesthesiallc [dot] com if you would like to join the Communique mailing list!
Visit www.anesthesiallc.com for more information!
Communiqué features articles focusing on the latest hot topics for anesthesiologists, nurse anesthetists, pain management specialists and anesthesia practice administrators.
Communique is created by Anesthesia Business Consultants (ABC), the largest physician billing and practice management company specializing exclusively in the practice of anesthesia and pain management.
ABC serves several thousand anesthesiologists and CRNAs nationwide with anesthesia billing software solutions.
Please send your email address to info [at] anesthesiallc [dot] com if you would like to join the Communique mailing list!
Visit www.anesthesiallc.com for more information!
In this presentation from the Beryl Institute's 2016 Patient Experience Conference, Edwards-Elmhurst Healthcare’s ED Chair and Patient Experience Director detail how they are leveraging technology to follow up with ED Patients and the exceptional results they’ve enjoyed.
Medical errors are ubiquitous and the costs (human and financial) are substantial. The top priority must be to redesign systems geared to prevent, detect and minimise effects of undesirable combinations of design, performance, and circumstance.
Presentation given at the Sidney R Garfield Center for Health Care Innovation, with other colleagues, on the potential for integrating social media into an integrated care system.
Orthopaedic Care Shifts to Outpatient and Urgent Care ClinicsApril Bright
The Shift in Care Delivery - As the healthcare delivery system evolves, hospitals may no longer be the first stop for patients seeking orthopaedic care. This is evidenced by the growing trend of surgeons moving to the outpatient setting, as patients seek less invasive procedures. Orthopaedic urgent care centers have also emerged as a viable alternative, due to their ability to address price concerns in the industry by reducing time and overhead costs for both providers and patients.
Attendees gain more insight into this shift, and learn how it will affect demands on manufacturers from a product design and delivery standpoint.
The De-Identification of a Large Electronic Medical Records Database for Seco...Luk Arbuckle
Over the last decade Canada has seen extensive reforms, investments, and innovations in primary health care. The Canadian Working Group for Primary Healthcare Improvement recommended that performance reporting be a strategic priority in moving towards transforming the primary health care system. To enable scalable and sustainable performance measurement and reporting, automated data collection from electronic medical records (EMR) will be necessary. EMR data can also play an important role in adverse drug event detection and public health surveillance.
Risk Management and Patient Safety Evolution and Progress. Charles Vincent. Match Safety critical component of quality (Madrid, Ministry of Health and Consumer Affairs, 2005)
patient safety and staff Management system ppt.pptxanjalatchi
Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
patient safety and staff Management system ppt.pptxanjalatchi
What is Patient Safety? Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.
System design to produce safer care culture meassurement and infrastructure f...Proqualis
Apresentação de Carol Haraden 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.
Carol Haraden é PhD, Vice Presidente do Institute for Healthcare Improvement (IHI), é membro do time responsável por desenvolver desenhos inovadores no cuidado ao paciente. Atualmente, ela lidera os trabalhos do IHI na Escócia, Sul da Inglaterra, Dinamarca e Estados Unidos.
NSQIP 9-2007 Noel Eldridge FINAL 92407 for 925.pptxNoel Eldridge
Patient Safety Presentation to 2007 Veterans Health Association NSQIP Meeting - includes information on wrong site surgery, retained surgical items, human factors, and other topics
How to Use Data to Improve Patient Safety: A Two-Part DiscussionHealth Catalyst
As healthcare organizations continue to experience expenses growing faster than revenues, value based care, and consumer transparency of costs and quality, patient safety will be an important determinant of success. This session will describe the sociotechnical attributes of a safe system, the challenges, the barriers and opportunities, and how to use data and your culture of safety as a powerful tool to drive down adverse events.
Attendees will learn:
Why patient safety and quality are important.
How data can help improve patient safety.
The history of patient safety and where we are today.
What components make up a safety analytics culture.
How the internal safety culture directly impacts patient safety metrics.
To describe basic guidelines for improving a safety culture with analytics.
Objectives:
1.Introduce the Measuring and Monitoring of Safety Framework to a Canadian healthcare audience
2.Describe how the framework would work in Canada
A presentation given by international keynote speaker Dr. Stephen Muething from Cincinnati Children's Hospital, USA at the CHA conference The Journey, in October 2012.
This portfolio includes three research-focused design projects and my thesis. Thesis topic: A tool (toy) to alleviate the emotional struggles that children with ADHD face each day.
Patient safety disparities presentation from 2015 CDC National Conference on ...Noel Eldridge
My portion of a panel presentation with 3 other speakers at conference session "CC6" on August 25, 2015. Will update when all conference slides are posted to public. Current web link as of September 19, 2015 is: http://www.cdc.gov/nchs/events/2015nchs/program_tuesday.htm#c6
Disparities in Patient Safety - Presentation from 2013 Maryland Patient Safet...Noel Eldridge
Presentation provided at Conference in 2013 based on data from the Medicare Patient Safety Monitoring Sytems (MPSMS). Prepared and delivered a similar presentation in August 2015 updating this information and including published data from 2014. This newer presentation is on-line at http://www.slideshare.net/neldridge202/patient-safety-disparities-presentation-from-2015-cdc-national-conference-on-health-statistics
TIPS issue on the 2004 Joint Commission National Patient Safety Goals (NPSGs) - Starting with this issue, I authored or co-authored every annual issue on the NPSGs through 2010.
Presentation on the results to date of the Federal Partnership for Patients (...Noel Eldridge
This is the full set of the introductory slides and my slides covering the presentation. The sponsoring organization, Consumers Advancing Patient Safety (CAPS), which invited me to give this presentation, has posted a version with the audio and video together on-line at: http://iteleseminar.com/71861610
Crew Resource Management Slides - including Handoffs - from 2008 National Pat...Noel Eldridge
Presentation on Crew Resource Management and Team Training in the Department of Veterans Affairs. Dr. Dunn did most of the presentation, and I covered the handoffs portion. (Afterward someone from NPSF told me that this was the highest-rated breakout session at the conference.) One related video is on Youtube at: https://www.youtube.com/watch?v=aYZx1l8rkXA . A story on the software tool we developed for handoffs is at this website, see pages 12-13. http://www.va.gov/opa/publications/vanguard/09janfebVG.pdf
An article on the tool in the Joint Commission Journal is on-line at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2010/00000036/00000002/art00003 Sorry it's not a full-text freebie. If you would like a pdf copy of it you can email me at neldridge202@yahoo.com.
Hand Hygiene Requirements and JCAHO National Patient Safety Goals in VHA 2003Noel Eldridge
Special TIPS (Topics in Patient Safety) newsletter issue on Hand Hygiene and the JCAHO (before rename to JC) NPSGs. The Summary of the CDC's guidance, if I remember correctly, is what was attached to the USH's memo to all VA facilities, if I remember correctly...
Hand Hygiene Presentation for February 2004 Veterans Health Administration "Q...Noel Eldridge
This presentation made clear the VHA policy to implement the CDC hand Hygiene Guideline a year before the VHA Directive was issued. A special memo and summary had been sent to VA Network Offices and Medical Center Directors from the Under Secretary for Health (Dr. Roswell). Will post the "TIPS" issue mentioned in slides. Memo has probably been lost in the mists of time. I have a video of this presentation (because it was broadcast on the VA's internal education system) on VHS and someday may get it on YouTube...
APIC "Futures Summit" Presentation April 2006Noel Eldridge
This was a presentation that I was invited to give at a "Summit" - Special Board meeting with invited guests - of the Association for Professionals in Infection Control. I remeember Rick Shannon also speaking and being impressed by his work, and CDC being there too. I was invited to talk about incentives for improving patient safety in VA, and I also added in slides about my frustration with the data on HAIs at that time.
Hand Hygiene Directive: Veterans Health Administration Directive 2005-002 ha...Noel Eldridge
This was the Department of Veterans Affairs first hand hygiene directive. It was based on the requirements of The Joint Commission (for Accredittion of Healthcare Organization's National Patient Safety Goal) requirement to implement the parts of the 2002 CDC Guideline for which there was strong evidence.
Improving Patient Safety Using Other-Than-"Evidence-Based" PracticesNoel Eldridge
Looks at PS and what has been done in other areas (like auto safety) to improve safety. Argues that action should be taken in the absence of surety that the action will work - based on prior rigorous scientific studies.
Presentation on Patient Safety Measurement for visitors from Sweden in 2007Noel Eldridge
This presentation was put together on the special topic of measurement when a group from Sweden was visiting the Dept of Veterans Affairs National Center for Patient Safety to learn about patient safety improvement programs underway there. I remember some of the people listening resisting my main point that so far there was no good way to measure PS outcomes, but some good ways to measure important outcomes that are potential precursors to patient safety problems (like not getting X-rays verified in a timely way).
2001 Presentation to the NCVHS on VA's National Center for Patient SafetyNoel Eldridge
I think this was the first NCPS presentation I gave to an outside group of experts. The topic was the program itself and how it worked, and what it was trying to accomplish and what it was accomplishing. I had been in the job for about a year at this point. The meeting minutes are on-line at: http://www.ncvhs.hhs.gov/011212mn.htm One of the other presenters was Jim Battles of AHRQ. Now he and I have offices next door to each other at AHRQ (where I've been since 2010).
Large-Scale Disclosure Panel Presentation from 2008 Annual Meeting of America...Noel Eldridge
I was invited to present on a panel on the disclosure of adverse events at this annual meeting of the American Society for Bioethics and Humanities in Cleveland, and covered the VA policy at that time. I had been involved in the implementation of the policy and the writing of the policy documents, but not the core thinking behind the policy which was developed by a committee convened by the VA Center for Ethics in Health Care a few years earlier. Disclosure of adverse events is an area where VA has been a leader, but it has been challenging, especially in gray areas such as when it is unknown whether any patients were actually harmed by a breach in appropriate practices. The current VA policy is on-line at: http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2800 . Also on-line is a 2008 transcript when I participated as a speaker in a national VA call organized by the VA National Center for Ethics in Health Care: http://www.ethics.va.gov/docs/net/NET_Topic_20080226_Disclosure_of_Adverse_Events.doc
Presentation at 2007 Annual Meeting of VA Patient Safety Managers and OfficersNoel Eldridge
This presentation was for 150 or so Dept of VA Patient Safety managers with and for whom I worked at VA Central Office while they worked at the VA Medical Centers and Network offices. The main items of interest are the preliminary work that I was describing from the periphery of the then developing VA MRSA Prevention Program, which was quite successful and led by Dr. Rajiv Jain (and published in NEJM: http://www.nejm.org/doi/full/10.1056/NEJMoa1007474#t=abstract). Also of interest is the wide-ranging work that VA NCPS led on the follow up on an OIG report that identified problems in some of VA's operating rooms. Also of interest is slide 36 where I present some interesting data on VA's reduction in unadjusted inpatient mortality - this hasn't been widely publicized or published to my knowledge. The second to last slide refers to the fact that the day after the meeting I was going to the Grand Canyon and planning to hike to the bottom one day and out the next day. That turned out to be a great experience.
April 2005 Medication Safety Presentation for IOM CommitteeNoel Eldridge
This presentation was made to the group that produced this report, The Future of Drug Safety: Promoting and Protecting the Health of the Public; which is online at: http://www.iom.edu/reports/2006/the-future-of-drug-safety-promoting-and-protecting-the-health-of-the-public.aspx. This was a big deal for me because it was the first time I presented to an IOM committee after having worked at the IOM's sister organization, the National Reseach Council, for 5 years, earlier in my career. I rmeember meeting my future boss at AHRQ, Dr. William Munier, for the first time at this meeting. Michael Valentino of the VA's Pharmacy Benefits Management Program was kind enough to come along with me that day in case I was asked drug questions that I couldn't answer.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Presentation at 2007 Meeting of Indian Health Service in San Diego
1. Patient Safety:
Why Bother?
Noel Eldridge, MS for
James P. Bagian, MD, PE
Chief Patient Safety Officer
Director, VA National Center for Patient Safety
February 28, 2007
james.bagian@va.gov & noel.eldridge@va.gov
www.patientsafety.gov
2. (Jimi couldn’t make it today. You got Noel.)
James Bagian, MD, PE
Director, VHA National Center for Patient Safety
Noel Eldridge
Executive Officer, NCPS
3. VA Statistics (FY 2005)
7.7M enrollees, 5.3M uniques
VA Medical Centers (Hospitals): 156
Admissions: 587,000
Community Based Outpatient Clinics: 708
Outpatient Visits: 57.5M
Rx Dispensed (30-day equiv): 231M
Lab Tests: 215.9M
Total FTE: 197,800
4. Veterans Health AdministrationVeterans Health Administration
2211 Veterans Integrated Service NetworksVeterans Integrated Service Networks
I J 2 0 0 2N A N U A R Y
W E R E IN T E G R A T E D A N D
R E N A M E D
V IS N 1 3 1 4
V IS N 2 3
S A N D
6. Institute of Medicine Goals
1. Safe – “avoiding injuries to patients from the care
that is intended to help them”
2. Timely
3. Efficient
4. Effective
5. Equitable
6. Patient-Centered
(from Crossing the Quality Chasm, 2001)
7. NY Times and W. Post This Week
Medication Reconciliation & Adverse Events
– “Unintentional drug poisonings accounted for
nearly 20,000 deaths in 2004, said the CDC,
making the problem now the second-leading
cause of accidental death in the United States,
after automobile accidents.”
• W. Post – 2/27/07
– “In August 2006, the Institute of Medicine of the
National Academies released a major study on
medication errors in American hospitals that found
that adverse drug events harm more than 1.5
million people and kill several thousand a year,
costing at least $3.5 billion annually.”
• NY Times – 2/25/07
8. Where Healthcare Was/Is
Cottage Industry Mentality
Virtually Total Reliance on:
– Professional/Individual Responsibility
– Individual Perfection
– Train and Blame
Little Understanding of Systems
Relative to People and Processes
– Ignorance vs. Arrogance
Culturally Different!!!!
9. Where Does a
Culture of Safety Exist?
Would you agree to fly on a bankrupt
airline to save $100?
Would you agree to get elective surgery
at a bankrupt hospital to save $100?
Are your answers different? If so, why?
Do you trust the airline “system” of
regulators, managers, pilots, and
mechanics in a different way than you
trust the healthcare “system”?
10. Sad Comment at amazon.com
Take this Book to the Hospital With You:
A Consumer Guide to Surviving Your
Hospital Stay
(4.5 stars)
by Charles B. Inlander
Buy this book with
How to Get Out of the Hospital Alive
(4.5 stars)
by Sheldon P. Blau, Elaine Fantle Shimberg today!
Buy Together Today: $20.34
CAN YOU IMAGINE THE EQUIVALENT FOR AN AIRLINE TRIP?
11.
12. NAVAL AVIATION MISHAP RATE
776 aircraft
destroyed in
1954
FY 50-96FY 50-96
Fiscal Year
2.39
39 aircraft
destroyed in
1996
0
10
20
30
40
50
60
50 65 80 96
Angled Carrier Decks
Naval Aviation Safety Center
NAMP est. 1959
RAG concept initiated
NATOPS initiated 1961
Squadron Safety program
System Safety
Designated Aircraft
ACT
HFC’s
ClassAMishaps/100,000FlightHours
13.
14. Three Important Questions
1. What Happened?
2. Why Did it Happen?
3. What Should We Do to Prevent it from
Happening Again?
15. Typical Healthcare Approach
New Policies, Regulations,Reporting
Systems, Training
Good First Step But…..
– Lack of Systems Insight
– Superficial Solutions (?Answers)
– Inadequate Follow-Up
– Lost Opportunity
16. Goal Selection
Clear
– Not Confused With Tactics
Compelling
– Relevance To Those Who Must Take Action
– Early Stakeholder Involvement in Goal Definition
Reinforced By Leadership
– Visible Participation
• All levels – not hierarchical
17. Goal: Prevent Harm
VA Patient Safety Advisory - August 8, 2000
Item: Medtronic Dual Chamber Temporary
Pacemaker model 5388
Specific Concerns: The Medtronic Dual Chamber
Temporary Pacemaker model 5388 may become
inactive if a button is touched while it is in "self test"
mode. If this occurs the pacemaker display freezes,
will not work properly and displays an error code of
0004. At this point the pacemaker cannot be turned
off. In order to correct the situation the battery
drawer has to be opened. Only removal of the
battery clears the error and turns the pacemaker off.
It may then be restarted.
18. Typical Missing Features
Clear Understanding of Goal
Preventive Approach
Field Understanding & Buy-In
Systems Approach
Sustainability
Trust/Culture of Safety
19. Safety System Design
High Reliability Organizations
Role of Reporting
– Learning or Accountability?
Systems-Based Solutions
– Patient Centered – DUH!!!!
Importance of Close Calls
20. VA Patient Safety Data & Feedback
Incidents reported have monotonically
increased since reporting to NCPS
started in 2000.
VA inpatient mortality down ~35%
from 1999 to 2006.
– (Remember: “Correlation is not causation.”)
21. VA Annual Events Reported
(including close calls) is Still Going Up
26. Most VA Reports are Actual “SAC 1s”
(events with little or no harm, or close calls)
27. Which Events get RCAs?
Many RCAs
are done on
events that
are not
Actual 3s.
Numbers are
surprisingly
constant
since 2001.
Is fewer
actual SAC3s
since 2001 &
2002 good
news?
Maybe.
28. RCA Categories (Coded by NCPS)
Selected Event (FY 2005) for Individual RCAs Percent
Fall 13.9%
Delay in Treatment/Diagnosis/Surgery 10.7%
High Alert Adverse Drug Events 10.5%
Unexpected Death 7.2%
Misidentification 6.3%
Missing Patient 4.9%
Hospital Acquired Infections 4.7%
Outpatient Suicide 3.4%
Correct Surgery 3.3%
65.0%
29. What about the Adverse Events and
Close Calls that don’t get “RCAed”?
In VA Aggregated Reviews are
performed at the local level, one per
quarter on:
1. Adverse Drug Events
2. Missing and Wandering Patients
3. “Parasuicidal” Events
4. Falls
– (When they are not “SAC 3” events)
30. Guiding Principles For Patient
Safety System
Learning, Not Accountability System
Reporting System Characteristics
• Non-punitive - Confidential and De-identified
• Internal and External
Importance of Close Call
Reports Should Emphasize Narratives
Interdisciplinary Review Teams
About Identifying Vulnerabilities NOT
Statistics
Prompt Feedback
Open to All Comers
31. What comes from RCAs?
1. Local Fixes and Learning
2. Local Insight into Better Methods for
Improvement and the Tractability of
Problems (not like the weather)
3. VA-wide Alerts and Advisories
4. Systemwide Learning and Informed
policymaking
32. VA RCA data on Incorrect Surgical
Procedures (2001 – 2005)
In-Operating Room: 33%
Out-of-Operating Room: 42%
Eye Procedures (can be either setting): 25%
33. What was Wrong? (2001-2005)
26 27
16
10
22
0
5
10
15
20
25
30
Wrong
Patient
Wrong
Side
Wrong
Site
Wrong
Procedure
Wrong
Implant
Percent
EXAMPLES…
Patient: Similar
Diagnosis or
Name
Side: Other
Side Similar
Diagnosis
Site: On Spine
or Hand/Wrist
Procedure:
Biopsy vs.
Cystoscopy
Implant: Lens
34. VA RCA data on Retained
Surgical Items, 2000-2005
Sponge
, 52
Towel,
5
Other,
8
36. Safety & Human Error:
Challenges
Healthcare Views Errors as Failings
Which Deserve Blame - Fault
Train and Blame Mentality
Blind Adherence To Rules
Corrective Actions Focusing on
Individual
No Blood No Foul Philosophy
37. Safety & Human Error:
Cornerstones
People Don’t Come to Work to Hurt
Someone or Make a Mistake
Must Keep Asking “Why?”
38. Safety – Human Error
Technical
Individual
Team
Profession
Institution
Policies/Procedures
Accident
LATENT
FAILURES
DEFENSES
Incomplete
procedures
Regulatory
narrowness
Mixed
Messages
Production
pressures
Responsibility
shifting
Inadequate
training
Attention
Distractions
Clumsy
Technology
Deferred
Maintenance
39. Patient Safety - Strategy
Invite People to Play
– Problem Recognition
– Remove Barriers (Punitive, Difficulty, Black
Hole Effect)
– Learning NOT Accountability System
Importance of Close Call
Blameworthy Definition
Training (Middle thru Top Management)
Leadership At All Levels
Human Factors Approach
– Tools That Guide Behavior
41. Prioritize
Risk Based
– Severity
– Probability
Must Make Sense
– Business Processes
– Regulatory Environment
42. Systematic
Cause and Effect
Human Error Must Have Preceding
Cause
Failure to Follow Procedure By Itself Is
NOT a Root Cause
Negative Descriptors Aren’t Actionable
Failure To Act Is not Cause Without
Pre-existing Requirement To Act
Why,Why,Why
43. Causation/Actions:
Who vs.What &Why
Who
– ‘Whose Fault Is This?’
– Actions focused on correcting individual
– ‘Corrects’ only after problem occurs
– Limited scope of action and generalizability
What & Why
– Actions focus on systems level causation
– Widespread applicability
– Stronger preventive strategy
44. Intentionally Unsafe Acts
“…events that result from: a criminal act; a
purposefully unsafe act; an act related to
alcohol or substance abuse by an impaired
provider and/or staff; or events involving
alleged or suspected patient abuse of any
kind.”
Intentionally Unsafe Acts are off-limits to
Patient Safety (RCA) review, everything else
is within limits
47. This was not an aerobic exercise
Demonstrates: “paired associate
learning”
48. Medical Software Correlation
- Pharmacist uses 95% of time.
- “Enter” button enters data.
- Pharmacist uses 5% of time.
- “Spacebar” enters data.
49.
50.
51.
52.
53. “Take-away” on Human Factors…
Considering and acting on knowledge
regarding human capabilities,
limitations, and tendencies when
designing and operating devices and
systems
Not always “common sense”
54. Human Factors Engineering
and “Actions”
Warnings and labels (watch out!)
Training (don’t do that)
Procedure changes (work around that)
Interlock, lock-in, lock-out, etc (let me
design it so you can not do that – forcing
functions)
Is there one right action???
Weaker
Stronger
56. Stronger
Actions
• Architectural/physical plant changes
• New devices with usability testing before purchasing
• Engineering control or interlock (forcing
functions)
• Simplify the process and remove unnecessary steps
• Standardize on equipment on process or caremaps
• Tangible involvement and action by
leadership in support of patient safety
Intermediate
Actions
• Redundancy
• Increase in staffing/decrease in workload
• Software enhancements/modifications
• Eliminate/reduce distractions (sterile medical
environment)
• Checklist/cognitive aid
• Eliminate look and sound-alikes
• Readback
• Enhanced documentation/communication
Weaker
Actions
• Double checks
• Warnings and labels
• New procedure/memorandum/policy
• Training
• Additional study/analysis
61. Alert based on “wrong-tube” RCAs
Veterans Health Administration Warning System
Published by VA Central Office
AL06-012 April 6, 2006
– Item: Mix-up (wrong route of administration) of bladder
irrigation with intravenous (IV) infusions
– Specific Incidents: Since 2001, VA facilities have reported
five cases of accidental infusion into an IV line or PICC line.
Amphotericin B (Attachment #1) was given intravenously
when it was intended for irrigation of the bladder via a
catheter. The same adverse event could occur with Glycine.
Amphotericin B and Glycine are both contraindicated in
patients with kidney or liver disease and when Amphotericin
B is infused via IV line, it can induce serious complications
(e.g., kidney failure).
63. Redundancy vs. Double-check
in Spelunking (Caving)
Two choices of
equipment
1. One flashlight
batteries checked twice
2. One flashlight and
one headlamp
70. Is There A Business Case?
YOU BET!!!
Examples:
– “Easy CAP” CO2 Detector
• $154/detected esophageal intubation
– RCA/40person-hrs X 12RCA/yr
• 0.25FTEE
71. Devices to prevent Out-of-OR Esophageal
Intubations are Cost-Effective
Description Equation =
Numerator Cost to implement (11,000
[# of codes] x $10)
$110,000
Denominator Number of recognized
events (assuming 100%
prevention effectiveness)
715
Cost-Effectiveness
Measure
$110,000 / 715 $154
Interpretation
It will cost $154 to detect one
unanticipated esophageal intubation
($10 per use at a rate of 6.5%)
72. Benefit-Cost of Patient Safety
National Center for Patient Safety,
Regional Patient Safety Officers, Facility
Patient Safety Managers, Local RCA
teams
~$130k per VA Medical Center (0.1%)
If this is a VA facility’s budget
This is Patient
Safety’s Share
73. Some Interventions have Zero Cost
Use of Antimicrobial Soap in VAMCs
43
19
38
3 16
81
0
10
20
30
40
50
60
70
80
90
Use Antimicrobial
Soap Only
Use Non-
antimicrobial
Soap Only
Use Both Types
of Soap
Percent(N=~120)
Dec-03
May-04
See Hand Hygiene Tools on www.patientsafety.gov
75. Sustainable Systems Approach
Problem Identification
Clear Goal Definition
Involvement Of All Sectors
Identify Systems Influences
Identify Systems Controls
Identify Constraints
Critique – Go To Worst Critics Early On
Pilot – Volunteers First Then Others
Evaluate
76. Critical Elements
Safe for Reporters/Participants
Prioritization Method
What is Blameworthy
Not About Fault – 3 W’s
Human Factors Engineering Tools
– Triage Cards, RCA Method
Concur/Not Concur (Mgmt/Leadership)
Feedback
Dedicated Patient Safety Duties
77. Closing Thoughts
Not About Errors!!!
Counting reports is not the objective,
identifying Vulnerabilities is
– Hope they increase
–Analysis, Action, & Feedback
are the key
Prevention NOT Punishment
Cultural change is the key – takes time
Safety is the Foundation
Upon which Quality is Built
78. Safety as the Foundation?
Quality programs can ensure that we use
evidence-based medicine to determine
which cardiac patients…
– Are prescribed the most appropriate of many
medications, and/or
– Get angioplasty with or without drug-eluting or
bare metal stents, and/or
– Get CABG surgery
But if they get surgical site and/or urinary
tract infections, and/or fall in the hospital…
– Can you call this High Quality Care???
79. Why Bother?
1. The Problem is Real
2. You Can Do Things to Make it
Better
“They say that time changes
things, but you actually have to
change them yourself”
Andy Warhol
80. Recently we have received a number of questions about whether is
it legal to buy facial tissues. At issue is whether or not the facial tissues are considered personal items.
We have discussed this issue with Department logistic and financial staff as well as VHA clinical staff.
The following provides a basis for the decision that was reached:
For patient-care areas and areas frequented by those who come in direct contact with patients, facial tissues should be considered
similarly to other expendable supplies that VA workers may use as they perform their duties during work hours. For example, VA
supplies disposable respirators, gloves, and surgical scrubs and gowns, all of which are employed by staff to protect patients from the
spread of infectious agents. This type of expenditure is clearly appropriate. On the second point, recent guidance from the CDC,
JCAHO, the National Health Information Center of the Department of Health and Human Services, and the American Lung Association
have all included recommendations for using tissues to cover coughs and sneezes to prevent the spread of infectious agents. First
among these infectious agents are viruses that cause upper respiratory infections such as cold and flu, but another agent of concern is
Staph. aureus (SA), including methicillin-resistant SA (MRSA), either of which can cause skin and wound infections. Various estimates
put the percentage of healthcare workers whose nasal passages are colonized with SA at about 30-40%. (The percent colonized by
MRSA is not well described and seems likely to vary widely.) SA and MRSA can be expelled from the nose during a sneeze and live for
days or weeks on substrates such as clothes, linens, curtains, countertops, and other environmental surfaces where they can be picked
up on hands or transferred to other surfaces and eventually patients. Using a tissue to reduce the dispersion of droplets and the gross
contamination of hands or clothes is imperfect but is widely recommended as a basic measure to control the spread of infectious agents.
Conclusion: Facial tissues to be used in patient care areas and
areas frequented by those who come in direct contact with patients
can be purchased with appropriated funds. This memo should not be taken as a mandate
to generate any new requirement to provide tissues in specific locations or at any pre-set density. Decisions on this topic should be
made locally and incorporate local circumstances and considerations.
(Agreed upon by: Fiscal, Accounting, Legal, Network Clinical
Managers, Public Health, Environment of Care, Infectious
Diseases, Patient Safety, in about 3 weeks.)
81. Are we there yet?
“From a certain point forward there
is no longer any turning back. That
is the point that must be reached”
- Franz Kafka
I look a little more like Noel Redding than he does like Jimi Hendrix.
Bankrupt or nearly bankrupt airlines: United, US Airways, ATA. Is there really such a thing as “ The Healthcare System ” Consider adding chart on definition of system.
This first book has been in print for at least 15 years. Isn ’ t this kind of embarrassing? Would anyone fly on an airplane if there was a market for books like this?
All reporting - is in the end - voluntary
Do 4 or 5 times. Hit table the same time. Last time only hit table (some will raise hands).
Pattern recognition. Taking shortcuts. Do we have any systems where we do repetitive actions that might have more than one action? Demonstrates a low level brain response. Training yields a low level auto response, telling someone not to do something under these conditions won ’ t be effective.
Not a lot of evidence that this made things better. But who knows, reporting of lawnmower accidents probably is not the most accurate
NOTE: The $5.2M figure does NOT include PSRS. The raw budget figure for the office is $8.278m for FY05.