The document introduces the topics of improving patient safety through a just culture approach, comprehensive unit-based safety programs, and safe patient handling and mobility. It discusses how medical errors can be reduced by understanding human fallibility and designing safer systems, and presents principles of safe design that can be applied to both technical processes and teamwork. Examples of assistive devices and national standards for safe patient handling and mobility are also reviewed.

1. Introduction to the Science ofIntroduction to the Science of
Improving Patient Safety, JustImproving Patient Safety, Just
Culture and Safe Patient Handling &Culture and Safe Patient Handling &
MobilityMobility
Dennis Jones, DNP, RN, NREMT-P
Safety & Quality Officer
Lifeline Critical Care Transport Team
Johns Hopkins Hospital
Instructor – JHUSON

2. Learning ObjectivesLearning Objectives
• To recognize that every system is designed to achieve the results it
gets
• To identify the basic principles of safe design that apply to both
technical and team work
• To discuss how teams make wise decisions
To identify the basic purpose of a Comprehensive Unit - based
Safety Program (CUSP) team
The content for the above objectives from Department of Patient
Safety – Johns Hopkins Hospital. Used with permission.
• To discuss the rationale for, and identify components of, Safe
Patient Handling & Mobility (SPHM) Interprofessional National
Standards
• Identify a variety of assist devices to be used in SPHM.

3. The problem of keeping patients safeThe problem of keeping patients safe
is largeis large
In U.S. Healthcare system
• 7% of patients suffer a medication error
• Every patients admitted to an ICU suffer adverse
event
• 44,000- 98,000 deaths
• $50 billion in total costs
• Similar results in UK and Australia
Kohn To err is human

4. The image of Patient Safety for JHHThe image of Patient Safety for JHH
Josie King – 18 months old
• Admitted to JHH January 2001 after suffering
60% BSA (2nd
degree, or partial thickness burns)
• Josie stayed in JHH PICU from admission to just
before Valentines day when she was moved to
IMCU.
• Pt developed vomiting, and diarrhea, confirmed
CLABSI. Placed on oral Antibiotics (no IV access)
and eventually became dehydrated, lethargic
and unresponsive. Treated with Narcan, and
Josie was allowed to drink (1 liter of fluid).
Methadone was d/c’d.
• Per mom, Josie continued to look bad, and a
pain specialist thought she should return to
PICU but attending surgeon said no. Pain
specialist recommended ½ original dose of
methadone to prevent withdrawal. 1 dose of
oral Methadone given. Pt went into cardiac
arrest, resuscitated for long period. Was brain
dead and removed from life support on 2/22.

5. How can such an event happen?
• People are fallible
• Medicine is still treated as an art, not science
• Need to view the delivery of healthcare as a
science
• Need systems that catch mistakes before they
reach the patient

6. How Can We Improve?How Can We Improve?
Understand the Science of SafetyUnderstand the Science of Safety
• Every system is perfectly designed to achieve the results it gets
• Understand principles of safe design
– standardize, create checklists, learn when things go
wrong
• Recognize these principles apply to technical and team work
• Teams make wise decisions when there is diverse and
independent input
Caregivers are not to blameCaregivers are not to blame

7. Case study
Central line removal
•A woman with metastatic cancer was hospitalized in the
intensive care unit (ICU) for management of congestive heart
failure and acute-on-chronic renal failure. The nephrology service
initiated continuous venovenous hemodialysis through a
large-bore catheter inserted in the right internal jugular vein.
Two weeks later, a first-year renal fellow removed the catheter
while the patient was seated upright in a chair. The patient
became acutely hypoxemic and appeared to seize. Head imaging
revealed global central nervous system ischemia suspicious
for hypoperfusion. The patient survived but had neurological deficits
and died about 6 months later.

8. SystemSystem FailureFailure LeadingLeading toto ThisThis ErrorError
Catheter pulled with
Patient sitting
Communication between
resident and nurse
Lack of protocol
For catheter removal
Inadequate training
and supervision
Patient suffers
Venous air embolism
8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med,
2004.
9. Reason J, Hobbs A., 2000.

9. This is a test…This is a test…

10. What’s wrong with this picture?

11. What’s wrong with this picture?

12. What’s wrong with this picture?

13. What’s wrong with this picture?

14. What’s wrong with this picture?

15. Pharmacy Carbon Original

16. What’s wrong with this picture?

17. System Factors Impact SafetySystem Factors Impact Safety
HospitalHospital
Departmental FactorsDepartmental Factors
Work EnvironmentWork Environment
Team FactorsTeam Factors
Individual ProviderIndividual Provider
Task FactorsTask Factors
Patient CharacteristicsPatient Characteristics
InstitutionalInstitutional
10. Adapted from Vincent C, Taylor-
Adams S, Stanhope N., BMJ, 1998.

18. Principles of Safe DesignPrinciples of Safe Design
• Standardize
– Eliminate steps if possible
• Create independent checks
• Learn when things go wrong
– What happened
– Why
– What did you do to reduce risk
– How do you know it worked

19. Standardize - Line Cart ContentsStandardize - Line Cart Contents

20. Eliminate StepsEliminate Steps

21. Create Independent ChecksCreate Independent Checks

22. Principles of Safe Design Apply toPrinciples of Safe Design Apply to
Technical and Team WorkTechnical and Team Work

23. Basic Components and Process ofBasic Components and Process of
CommunicationCommunication
16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.

24. Teamwork ToolsTeamwork Tools
• Staff Safety Assessment
• Daily goals
• AM briefing
• Shadowing
• Barrier Identification and Mitigation
• Learning from Defects

25. SystemsSystems
• Every system is designed to achieve the results it gets
• To improve performance we need to change systems
• Start with pilot test
 one patient, one day, one provider, one RN, one
room

26. Comprehensive Unit-based Safety Program (CUSP)Comprehensive Unit-based Safety Program (CUSP) AnAn
Intervention to Learn from Mistakes and Improve Safety CultureIntervention to Learn from Mistakes and Improve Safety Culture
1. Educate staff on science of safety
http://www.hopkinsmedicine.org/quality_safety_research_group/
1. Identify defects
2. Assign executive to adopt unit
3. Learn from one defect per quarter
4. Implement teamwork tools
Timmel J, et al. Jt Comm J Qual Patient Saf 2010;36:252-260.

27. RecapRecap
• Accept that we will make mistakes
• Develop lenses to see systems and design to make
them safer
• Value the wisdom of frontline staff
• Work to standardize one process
• Infuse these principles of standardization and
independent checks in other processes
• Recognize culture is local
• Seek to expose (not hide) defects
• Don’t play man down
– Speak up when you have a concern
– Listen when others do

28. SPH&M
“The incidence rate of back injuries among nurses is more than
double that among construction workers, perhaps because
misperceptions persist about causes and solutions.”
Nelson, A.; Fragala, G.; Menzel, N. (2003). Myths and Facts About Back Injuries in
Nursing. American Journal of Nursing. 103(2), 32-40.
“A healthcare professional is the only professional who considers 100 pounds,
light”.
“If you have a 300 pound container in a warehouse that needs to be moved, how is
it done?” – forklift
“If you have a 300 pound patient in a hospital that needs to be moved, how has it
traditionally been done?” – you get more people.
D. Jones

29. SPH&M
• Manual handling/lifting of patients
• How much can (should) we lift?
• What are barriers to not manually
handling/lifting of patients?
• What are the potential negative outcomes to
manual lifting?
• So what do we do about it?

30. SPH&M – ANA Interprofessional
National Standards
1. Establish a culture of
safety
2. Implement and sustain a
SPH&M program
3. Incorporate ergonomic
design principles to
provide a safe
environment of care
4. Select, install, and
maintain SPHM
technology
5. Establish a system for
education, training, and
maintaining competence
6. Integrate Pt-centered SPHM
assessment, plan of care, and
use of SPHM technology
7. Include SPHM in reasonable
accommodation and post-
injury return to work
8. Establish a comprehensive
evaluation system

31. Examples of SPHM technology
Maxi-Move lift Maxi-move with patient

32. Examples of SPHM technology
Maxi – Sky ceiling lift
Maxi – Sky ceiling lift with
patient

33. Examples of SPHM technology
• Kreg Bariatric E-Z Wider
bed:
http://kreg.us/VideoArchive/EZWider/full/EZ2.7/index.cfm
• Air assisted lateral
transfer device

34. Conclusion
• Be aware of systems issues as you go through
nursing school
• Think safety, for the patient AND you.
• Take the time to get help, appropriate
equipment when moving patients
• Get involved in safety & quality committees
initiatives within your organization