Patient Safety Presentation to 2007 Veterans Health Association NSQIP Meeting - includes information on wrong site surgery, retained surgical items, human factors, and other topics
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).
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.
This document discusses surgical safety and errors. It notes that 234 million operations are performed globally each year, with 1 million deaths and 7 million disabling complications, over 50% of which are preventable. Common errors include wrong site, patient, procedure and retained instruments. Causes include lack of protocols, training, supervision, staffing issues and communication breakdowns. Aviation safety practices are presented as a model, with mandatory reporting and a non-punitive culture. The WHO surgical safety checklist is summarized, which was tested in 8 countries and significantly reduced complications and death rates. Universal adoption of checklists and a culture of safety are recommended to improve patient outcomes during surgery.
This document discusses surgical safety and errors. It notes that 234 million operations are performed globally each year, with 1 million deaths and 7 million disabling complications, over 50% of which are preventable. Common errors include wrong site surgery, wrong patient surgery, and retained surgical instruments. Causes of errors include lack of protocols, training, supervision, communication breakdowns, and operating outside of one's expertise. Checklists modeled after aviation safety checklists have been shown to reduce complications and deaths when used in surgery. A WHO surgical safety checklist was tested in 8 hospitals globally and significantly reduced death rates and complication rates. Universal adoption of checklists and a culture of safety are seen as keys to reducing preventable surgical errors.
This document summarizes a presentation on patient safety given by Dr. Annush Tha. It discusses the importance of patient safety and human factors in healthcare. It notes that medical errors are a leading cause of death globally and outlines strategies to improve safety, including checklists, reporting systems, and quality improvement. The role of surgeons in ensuring safety throughout the surgical pathway is emphasized. Newer approaches focus on performing procedures correctly from the start rather than just correcting errors.
Sociotechnical Aspects: Clinicians and Technology_ lecture 1_slidesZakCooper1
This lecture focused on medical errors and patient safety. It distinguished between individual "slips" and "mistakes" as well as system errors. Several types of medical errors were examined like medication errors and wrong site surgeries. Efforts to improve patient safety through initiatives like medication reconciliation were also discussed. The lecture concluded by reviewing organizations driving improvements in patient safety and quality of care.
Patient safety Incident (PSI) is an unplanned or unintended event or circumstance that could have resulted or did result in harm to a patient while in the care of a health facility. In this presentation, I explored the concepts of patient safety and patient safety incidents. I also explored the concept of Reporting systems, properly now known as reporting and learning systems - because learning is paramount in the reporting system. I focused on the minimal information model, which is more routinely used compared to the intermediate and full information models.
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).
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.
This document discusses surgical safety and errors. It notes that 234 million operations are performed globally each year, with 1 million deaths and 7 million disabling complications, over 50% of which are preventable. Common errors include wrong site, patient, procedure and retained instruments. Causes include lack of protocols, training, supervision, staffing issues and communication breakdowns. Aviation safety practices are presented as a model, with mandatory reporting and a non-punitive culture. The WHO surgical safety checklist is summarized, which was tested in 8 countries and significantly reduced complications and death rates. Universal adoption of checklists and a culture of safety are recommended to improve patient outcomes during surgery.
This document discusses surgical safety and errors. It notes that 234 million operations are performed globally each year, with 1 million deaths and 7 million disabling complications, over 50% of which are preventable. Common errors include wrong site surgery, wrong patient surgery, and retained surgical instruments. Causes of errors include lack of protocols, training, supervision, communication breakdowns, and operating outside of one's expertise. Checklists modeled after aviation safety checklists have been shown to reduce complications and deaths when used in surgery. A WHO surgical safety checklist was tested in 8 hospitals globally and significantly reduced death rates and complication rates. Universal adoption of checklists and a culture of safety are seen as keys to reducing preventable surgical errors.
This document summarizes a presentation on patient safety given by Dr. Annush Tha. It discusses the importance of patient safety and human factors in healthcare. It notes that medical errors are a leading cause of death globally and outlines strategies to improve safety, including checklists, reporting systems, and quality improvement. The role of surgeons in ensuring safety throughout the surgical pathway is emphasized. Newer approaches focus on performing procedures correctly from the start rather than just correcting errors.
Sociotechnical Aspects: Clinicians and Technology_ lecture 1_slidesZakCooper1
This lecture focused on medical errors and patient safety. It distinguished between individual "slips" and "mistakes" as well as system errors. Several types of medical errors were examined like medication errors and wrong site surgeries. Efforts to improve patient safety through initiatives like medication reconciliation were also discussed. The lecture concluded by reviewing organizations driving improvements in patient safety and quality of care.
Patient safety Incident (PSI) is an unplanned or unintended event or circumstance that could have resulted or did result in harm to a patient while in the care of a health facility. In this presentation, I explored the concepts of patient safety and patient safety incidents. I also explored the concept of Reporting systems, properly now known as reporting and learning systems - because learning is paramount in the reporting system. I focused on the minimal information model, which is more routinely used compared to the intermediate and full information models.
This document introduces the concept of patient safety and discusses occurrence variance reporting (OVR) and international patient safety goals. It notes that medical errors injure 1 in 25 hospital patients and kill 44,000-98,000 people per year in the US. The goals of patient safety are to detect safety issues, implement preventive actions, and reduce risks. OVR involves voluntary reporting of process variations to improve quality and prevent recurrences. It identifies adverse events, near misses, and sentinel events. The six international patient safety goals focus on correctly identifying patients, improving communication, increasing medication safety, ensuring correct surgical procedures, reducing healthcare-associated infections, and decreasing falls.
This presentation has the measures to be taken for the safety of patients. It covers the 6 goals
Goal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
This document provides an overview of patient safety and medical errors. It discusses the extent of the medical error problem, highlighting estimates of deaths per year. It emphasizes that a systems approach is needed, rather than focusing on individual blame. Examples of success in other industries like aviation and some areas of healthcare are provided. The document also discusses root cause analysis, designing safer systems, and initiatives like computerized physician order entry that can help reduce errors.
Improving Surgical Safety and Patient OutcomesC Daniel Smith
Keynote talk delivered at New Jersey Hospital Association Seminary on Improving Surgical Safety & Patient Outcomes held on September 25, 2013 at their Conference Center in Princeton New Jersey. Over physicians, administrators, nurses and perioperative services providers in attendance.
The document describes creating a just culture of safety in healthcare. It discusses influences on advancing safety culture including professional accountability and a just culture approach. A just culture emphasizes quality and safety over blame, promotes error reporting to uncover root causes, and uses coaching rather than punishment for unintentional errors. Examples of errors are provided to distinguish intentional reckless behavior from mistakes. The document also summarizes Massachusetts General Hospital's approach to developing a just culture including robust safety reporting, data analysis, and leadership involvement.
Patient safety assistantship Professor Vinod PatelVinod0901
This document provides an overview of a lecture on promoting patient safety in the NHS after the Berwick Report. It discusses the four ethical principles of autonomy, beneficence, non-maleficence and justice. It then describes elements of a professional skills suite including reducing inequalities, health promotion, patient safety, consent and more. Key models for understanding medical errors like the Swiss cheese model and human factors are presented. The document summarizes the Berwick Report which examined failings in care and made recommendations to improve patient safety, including being more open, transparent and prioritizing patient needs. It also discusses tools like the surgical safety checklist and their impact in reducing complications and deaths.
This document discusses the importance of electronic health records and clinical decision support systems for improving healthcare quality and reducing costs and errors. It notes that healthcare information is essential for providing and managing patient care. Clinical decision support systems can help ensure best practices are followed and reduce unnecessary tests and costs. However, the document also finds that healthcare practices still vary greatly between regions and clinicians due to complexity, uncertainty and lack of evidence. More high-quality data and decision support are needed to address these issues and improve consistent high-value care.
Presentation at 2007 Meeting of Indian Health Service in San DiegoNoel Eldridge
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.
This presentation was done by RUTAYISIRE François Xavier and ISHIMWE Diane, medical students at University of RWANDA School of Medicine and pharmacy, department of medicine and surgery. They did it while they were in Year 4 (Doctorate2), under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA. It tell us about what a surgical safety checklist is, and why is it important in surgical field.
This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA
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.
The document discusses missed and delayed diagnosis claims, which are the most expensive malpractice cases. It focuses on closing the referral loop as a way to address these issues. Two main contributing factors are identified: cognitive factors like clinical judgment; and systems factors like following up on test results and referrals. While cognitive factors require multipronged strategies, opportunities to improve systems like closing the referral loop are described as "low hanging fruit." The document outlines a referral management workgroup and technology solutions to help address gaps, though further work is still needed.
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
The document discusses medical errors and their relationship to negligence and malpractice litigation. Some key points:
- Medical errors are estimated to cause between 44,000-98,000 deaths per year in the US, making it a leading cause of death. However, other studies estimate a lower number of around 5,000 deaths due to errors.
- Only a small percentage (around 1-2%) of medical errors result in negligent injuries. Of those negligent injuries, only 10-13% result in malpractice claims.
- Common reasons for malpractice litigation include needing money, believing there was a cover up, or wanting information or revenge. However, the system rarely identifies or holds providers accountable for substandard care
Overview of Patient Safety & Quality of CareAhmad Al-Sadi
This document discusses quality and safety in healthcare. It defines key terms like quality of care, errors, adverse events and sentinel events. It describes national organizations that influence quality and safety like AHRQ, CMS and FDA. It discusses measuring quality and safety through core measures and indicators. Unwanted variation in healthcare is described. The importance of transparency and reporting performance is covered. The consequences of errors are outlined. Professional responsibilities for nurses in quality and safety are discussed, including preventing and responding to adverse events.
The document discusses various ways hospitals can improve patient safety and reduce medical errors in areas such as surgery, medication administration, infections, and diagnosis. It provides examples of how hospitals have successfully reduced errors rates in these areas through methods like checklists, standardized processes, computerized order entry, barcoding, and visual aids. Overall, the document advocates for applying lean problem solving methods to identify and address the root causes of common medical mistakes and adverse events.
The Covid-19 response in the USA has been much worse than in other countries like Canada and Jamaica, with 800,000 deaths so far. Former President Trump and his appointees as well as a lack of masking and testing contributed greatly to the poor response. The US healthcare system's costs also prevented some from seeking care. While vaccination has helped, the Delta variant has caused new waves and breakthrough cases show vaccination alone is not enough without other measures. Texas data shows the unvaccinated are over 10 times more likely to be infected or die from Covid. The Omicron variant is rising rapidly in parts of the US.
Presentation with Erin Grace to the Interoperability Standards Priorities Tas...Noel Eldridge
The document discusses AHRQ's work on patient safety surveillance and measuring adverse drug events. It provides an overview of AHRQ and its Center for Quality Improvement and Patient Safety (CQuIPS). It then discusses AHRQ's partnership with CMS to estimate national hospital-acquired condition rates using the MPSMS and its successor the QSRS. It provides examples of data on adverse drug events measured by MPSMS and discusses AHRQ's current project to electronically specify the C. diff infections module from QSRS.
More Related Content
Similar to NSQIP 9-2007 Noel Eldridge FINAL 92407 for 925.pptx
This document introduces the concept of patient safety and discusses occurrence variance reporting (OVR) and international patient safety goals. It notes that medical errors injure 1 in 25 hospital patients and kill 44,000-98,000 people per year in the US. The goals of patient safety are to detect safety issues, implement preventive actions, and reduce risks. OVR involves voluntary reporting of process variations to improve quality and prevent recurrences. It identifies adverse events, near misses, and sentinel events. The six international patient safety goals focus on correctly identifying patients, improving communication, increasing medication safety, ensuring correct surgical procedures, reducing healthcare-associated infections, and decreasing falls.
This presentation has the measures to be taken for the safety of patients. It covers the 6 goals
Goal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
This document provides an overview of patient safety and medical errors. It discusses the extent of the medical error problem, highlighting estimates of deaths per year. It emphasizes that a systems approach is needed, rather than focusing on individual blame. Examples of success in other industries like aviation and some areas of healthcare are provided. The document also discusses root cause analysis, designing safer systems, and initiatives like computerized physician order entry that can help reduce errors.
Improving Surgical Safety and Patient OutcomesC Daniel Smith
Keynote talk delivered at New Jersey Hospital Association Seminary on Improving Surgical Safety & Patient Outcomes held on September 25, 2013 at their Conference Center in Princeton New Jersey. Over physicians, administrators, nurses and perioperative services providers in attendance.
The document describes creating a just culture of safety in healthcare. It discusses influences on advancing safety culture including professional accountability and a just culture approach. A just culture emphasizes quality and safety over blame, promotes error reporting to uncover root causes, and uses coaching rather than punishment for unintentional errors. Examples of errors are provided to distinguish intentional reckless behavior from mistakes. The document also summarizes Massachusetts General Hospital's approach to developing a just culture including robust safety reporting, data analysis, and leadership involvement.
Patient safety assistantship Professor Vinod PatelVinod0901
This document provides an overview of a lecture on promoting patient safety in the NHS after the Berwick Report. It discusses the four ethical principles of autonomy, beneficence, non-maleficence and justice. It then describes elements of a professional skills suite including reducing inequalities, health promotion, patient safety, consent and more. Key models for understanding medical errors like the Swiss cheese model and human factors are presented. The document summarizes the Berwick Report which examined failings in care and made recommendations to improve patient safety, including being more open, transparent and prioritizing patient needs. It also discusses tools like the surgical safety checklist and their impact in reducing complications and deaths.
This document discusses the importance of electronic health records and clinical decision support systems for improving healthcare quality and reducing costs and errors. It notes that healthcare information is essential for providing and managing patient care. Clinical decision support systems can help ensure best practices are followed and reduce unnecessary tests and costs. However, the document also finds that healthcare practices still vary greatly between regions and clinicians due to complexity, uncertainty and lack of evidence. More high-quality data and decision support are needed to address these issues and improve consistent high-value care.
Presentation at 2007 Meeting of Indian Health Service in San DiegoNoel Eldridge
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.
This presentation was done by RUTAYISIRE François Xavier and ISHIMWE Diane, medical students at University of RWANDA School of Medicine and pharmacy, department of medicine and surgery. They did it while they were in Year 4 (Doctorate2), under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA. It tell us about what a surgical safety checklist is, and why is it important in surgical field.
This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA
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.
The document discusses missed and delayed diagnosis claims, which are the most expensive malpractice cases. It focuses on closing the referral loop as a way to address these issues. Two main contributing factors are identified: cognitive factors like clinical judgment; and systems factors like following up on test results and referrals. While cognitive factors require multipronged strategies, opportunities to improve systems like closing the referral loop are described as "low hanging fruit." The document outlines a referral management workgroup and technology solutions to help address gaps, though further work is still needed.
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
The document discusses medical errors and their relationship to negligence and malpractice litigation. Some key points:
- Medical errors are estimated to cause between 44,000-98,000 deaths per year in the US, making it a leading cause of death. However, other studies estimate a lower number of around 5,000 deaths due to errors.
- Only a small percentage (around 1-2%) of medical errors result in negligent injuries. Of those negligent injuries, only 10-13% result in malpractice claims.
- Common reasons for malpractice litigation include needing money, believing there was a cover up, or wanting information or revenge. However, the system rarely identifies or holds providers accountable for substandard care
Overview of Patient Safety & Quality of CareAhmad Al-Sadi
This document discusses quality and safety in healthcare. It defines key terms like quality of care, errors, adverse events and sentinel events. It describes national organizations that influence quality and safety like AHRQ, CMS and FDA. It discusses measuring quality and safety through core measures and indicators. Unwanted variation in healthcare is described. The importance of transparency and reporting performance is covered. The consequences of errors are outlined. Professional responsibilities for nurses in quality and safety are discussed, including preventing and responding to adverse events.
The document discusses various ways hospitals can improve patient safety and reduce medical errors in areas such as surgery, medication administration, infections, and diagnosis. It provides examples of how hospitals have successfully reduced errors rates in these areas through methods like checklists, standardized processes, computerized order entry, barcoding, and visual aids. Overall, the document advocates for applying lean problem solving methods to identify and address the root causes of common medical mistakes and adverse events.
Similar to NSQIP 9-2007 Noel Eldridge FINAL 92407 for 925.pptx (20)
The Covid-19 response in the USA has been much worse than in other countries like Canada and Jamaica, with 800,000 deaths so far. Former President Trump and his appointees as well as a lack of masking and testing contributed greatly to the poor response. The US healthcare system's costs also prevented some from seeking care. While vaccination has helped, the Delta variant has caused new waves and breakthrough cases show vaccination alone is not enough without other measures. Texas data shows the unvaccinated are over 10 times more likely to be infected or die from Covid. The Omicron variant is rising rapidly in parts of the US.
Presentation with Erin Grace to the Interoperability Standards Priorities Tas...Noel Eldridge
The document discusses AHRQ's work on patient safety surveillance and measuring adverse drug events. It provides an overview of AHRQ and its Center for Quality Improvement and Patient Safety (CQuIPS). It then discusses AHRQ's partnership with CMS to estimate national hospital-acquired condition rates using the MPSMS and its successor the QSRS. It provides examples of data on adverse drug events measured by MPSMS and discusses AHRQ's current project to electronically specify the C. diff infections module from QSRS.
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
The document summarizes preliminary findings from the Medicare Patient Safety Monitoring System (MPSMS) regarding potential patient safety disparities. MPSMS measures 21 patient safety indicators, including adverse drug events, hospital-acquired infections, and complications from procedures. Preliminary analysis of 2010-2011 MPSMS data shows some disparities, with Black patients sometimes having higher exposure and adverse event rates than White patients for certain measures like hospital-acquired infections and adverse drug events. The small sample sizes for racial/ethnic subgroups limit the ability to detect all potential disparities. Combining multiple years of MPSMS data could provide more insights into disparities while addressing limitations of small sample sizes.
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.
Topics in Patient Safety - 2003 (Initial) Joint Commission National Patient S...Noel Eldridge
The document summarizes the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) first set of six National Patient Safety Goals for 2003. It provides details on each goal, including JCAHO's interpretation and intent, related information from the VA National Center for Patient Safety, existing facility resources that can help meet the goals, and specific actions facilities need to take to ensure compliance. The goals focus on improving accuracy of patient identification, effectiveness of communication among caregivers, safety of high-alert medications, prevention of wrong-site surgery, safety of infusion pumps, and effectiveness of clinical alarm systems. Facilities will need to demonstrate they have policies addressing the goals and develop outcome measures showing consistent meeting of the new
Presentation on the results to date of the Federal Partnership for Patients (...Noel Eldridge
The document discusses national estimates of hospital-acquired conditions (HACs) in the United States before and after the launch of the Partnership for Patients initiative. It provides an overview of the initiative's goals to reduce HACs by 40% and readmissions by 20% by 2014. Interim analysis of data from 2010-2013 shows a 17% reduction in the HAC rate, avoiding an estimated 35,000 deaths and saving $8 billion in 2013. The analysis indicates progress toward the initiative's goals but notes limitations in the measurement methods.
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.
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.
February 2004 Hand Hygiene Presentation at Meeting of the Veterans Health Adm...Noel Eldridge
This slide set is almost 10 years old, but it hits some good points. Especially about us knowing what doesn't work to reduce healthcare associated infections, and needing to do things differently. I have a video of this presentation on a VHS tape somewhere and need to figure out how to get it on YouTube like one I did at the conclusion of the Six Sigma Project referred to in these slides. http://www.youtube.com/watch?v=Zb_fVETGzwg
Some formatting is a little off in the translation to the current version of PowerPoint, but I didn't want to start editing and be tempted to change anything.
Federal HAI Data Summit May 2012 plenary two-master_slides noel slides 11 t...Noel Eldridge
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PET CT beginners Guide covers some of the underrepresented topics in PET CT
NSQIP 9-2007 Noel Eldridge FINAL 92407 for 925.pptx
1. 1
Patient Safety Presentation for
NSQIP SCNR Conference
Noel Eldridge, MS
VA National Center for Patient Safety
September 25, 2007
2. 2
Outline
• Background on Patient Safety, in general
and VA’s program
• Patient Safety Data and Information on
Surgery Topics
• Intro to Human Factors Engineering and
Actions to Prevent Adverse Events
• Wrap-up
3. 3
What is Safety?
• Safety is Freedom from Accidental Injury.
• Patient Safety Improvement is dedicated to
making patients free from accidental injury
as they receive healthcare.
– Not performing the wrong operation
– Not accidentally putting MRSA bacteria onto a
patient’s skin
– Preventing fall injuries, etc.
4. 4
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)
5. 6
NY Times and W. Post
• 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
6. 7
CDC’s Latest Estimate (2007)
• The estimated deaths associated with
healthcare-associated infections [for 2002] in
U.S. hospitals were 98,987: of these,
• 35,967 were for pneumonia,
• 30,665 for bloodstream infections,
• 13,088 for urinary tract infections,
• 8,205 for surgical site infections, and
• 11,062 for infections of other sites.
– Public Health Reports, March–April 2007, pp 160-166
7. 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!!!!
8. 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”?
9. 10
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13. 14
Three Important Questions
1. What Happened?
2. Why Did it Happen?
3. What Should We Do to Prevent it
from Happening Again?
(The answers are based on the
results of a local accident
investigation, such as a Root Cause
Analysis.)
14. 15
Three Other
Important Questions
1. What Happened?
2. What was Supposed to Happen?
3. What Usually Happens?
These questions are good for understanding
the role of the “normalization of deviance,”
i.e., a culture of ignoring the rules, e.g.,
Beltway norm of 70 mph when “speed limit” is
55 mph.
15. 16
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.”)
22. 23
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.
23. 24
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
24. 25
OIG Report on Patient
Safety in the Operating Room
www.va.gov/oig/54/reports/VAOIG-05-00379-91.pdf
25. 26
Purpose of the OIG Review
• To “determine whether”:
1. “facility leaders established and implemented
effective policies, procedures, and guidelines to
ensure patient safety in the OR”;
2. “facility leaders established surgical improvement
program and identifies potential problem areas
needing improvement; and
3. “there was coordination between Supply,
Processing, and Distribution (SPD) and the OR”
Eight (8) VAMCs Visited by OIG Staff
26. 27
Summary of Findings
• Issue 1: Compliance
with VHA Directives,
AORN Guidelines, &
JCAHO Standards
• Issue 2: Surgical
Performance
Improvement Program
• Issue 3: SPD
Coordination with the
OR
27. 28
Accentuating the Negative
• Ensuring Correct Surgery
– We found that …two (of 8) facilities… had policies that only
addressed side/site verification.
– We found that two (of 8) facilities… had incident or near
miss incorrect surgery events in fiscal year (FY) 2005.
• The first facility reviewed the event of the wrong site surgery and
determined that (a) the surgeon did not possess the consent form when
the site was marked, (b) the nurse circulator did not mention the
variance between the marked site and the consent, and (c) a time-out
briefing with the informed consent was not performed.
• At the second facility, a patient had the wrong eye anesthetized
(blocked)…The incident was reviewed and monitors were developed
and implemented to ensure the correct site was identified and marked.
• Related JCAHO Finding from 2006 Surveys
– 12 of 33 (36%) VAMCs received RFIs for “Universal
Protocol” (11 Time-outs and 1 Mark Operative Site).
28. 29
Accentuating the Negative
• Disclosure of Adverse Events
– We found that three (of 8) facilities failed to
document disclosure of adverse surgical events.
• At one facility, two patients had to return to surgery
with partially retained drains. (no record of
disclosure)
• At a second facility, the surgeon administered a
regional block into the wrong eye. (no record of
disclosure)
• In the third facility, we reviewed three surgery-related
deaths that involved delay in diagnosis or
treatment… (no record of disclosure)
29. 30
OR Self-Assessment Tools #2 & 3
Summary Results (Local Policy Reviews)
Step 1: Informed Consent. (No. of Question = 6) 94%
Step 2: Marking the Site. (No. of Question = 7) 94%
Step 3: Patient Identification: (No. of Question 6) 94%
Step 4: Time out: (No. of Questions = 11) 90%
Step 5: Checking Imaging Date: (No. of Questions = 4) 96%
Overall Percent Met (Total No. of Questions = 34) 93%
Overall Percent Met (Total No. of Questions = 22) 87%
RESULTS FOR OR SELF-ASSESSMENT TOOL #2 :
VHA Directive 2004-028: Ensuring Correct Surgery and Invasive Procedures -
Blank's & NA's Excluded from Total Count
RESULTS FOR OR SELF-ASSESSMENT TOOL #3 :
VHA Directive 2006-030: Prevention of Retained Surgical Items - Blanks &
NA's Excluded from Total Count
30. 31
RESULTS FOR OR SELF-ASSESSMENT TOOL #4
(MISCELLANEOUS POLICIES AND PROCESSES REVIEWED BY OIG)
Blanks & NA's Excluded from Total Count
Percent
Met:
VAMC Policy Review for Environment of Care (VHA Design Standards
2004-VHA OR-HVAC Design Criteria) and (JCAHO EC 1.7). (No. of
Question = 9) 73%
Operating Room Equipment Management. (No. of Question = 5) 94%
Operating Room and Invasive Procedure Committee. (No. of
Question = 4) 88%
VHA Directive 2005-056 Morbidity and Mortality Peer Review. (No. of
Questions = 4) 96%
Resident Supervision (regarding Surgery). (No. of Questions = 4) 97%
Advanced Cardiovascular Life Support and Basic Life Support
(ACLS and BLS Certification). (No. of Questions = 2) 93%
Disclosure of Adverse Events (VHA Directive 2005-049). (No. of
Questions = 4) 91%
Supply Processing, and Distribution Coordination with the Operating
Room. (No. of Questions = 3) 79%
Overall Compliance Met (Total No. of Questions = 36) 87%
OR Self-Assessment Tool #4
31. 32
What “Not Met’s” Add Up To
(VHA-Wide)
• Self Assessment Tool #2 (Ensuring
Correct Surgery): 287 Not Met’s
• Self Assessment Tool #3 (Prevention of
Retained Surgical Items): 350 Not Met’s
• Self Assessment Tool #4 (Various Policies
and Processes): 506 Not Met’s
• This is over 1,100 Not Met’s (as of 7/2007)
32. 33
Ensuring Correct Surgery
• Draft data from a paper in preparation
• We have more data on this topic that
anyone else we have been able to find…
33. 34
Percents of Reports of In-OR Incorrect Surgeries
and Percent of Surgeries, by Specialty
3%
4%
5%
9%
10%
24%
38%
2%
2%
5%
20%
31%
11%
11%
0% 10% 20% 30% 40% 50%
Podiatry
Neurosurgery
Vascular Surgery
Urology
General Surgery
Orthopedics
Ophthalmology Percent of VA
Surgical Cases (6
yrs of Surgery
Package data)
Percent of In-OR
Adverse Events
Reported to
NCPS (5.5 yrs)
34. 35
Percentage of Adverse Events in the OR
and Not in the OR (n = 212 total)
0% 10% 20% 30% 40%
Other
Wrong Procedure
Wrong Site
Wrong Implant
Wrong Patient
Wrong Side
OR
Non OR
35. 36
Tentative Take-Home Points
• Reports of Eye and Orthopedic cases
overrepresented compared to number of cases.
• Reports of classic “wrong-side in OR” cases are
only 20-25% of reports.
• Wrong implants are a special issue and are
almost as commonly reported in OR.
• We didn’t get reports from VAMCs that said “We
did everything right and it happened anyway.”
– Mark virtually all sites!
– Always get real Informed Consent!
– Always do a real Time-out!
36. 37
Retained Surgical Items
• Data from 2000 to 2005 that was used in
policy (Directive) development
• Data from NCPS reports since Directive
issued (6/2006 to 6/2007)
• NSQIP web site data on this topic not
shown (under review)
37. 38
Data Submitted by VAMCs to NCPS
Retained Surgical Items,
by Type of Item, 2000-2005
Sponge,
52, 80%
Towel, 5,
8%
Other, 8,
12%
38. 39
Retained Items Reports to NCPS (6/06 to 6/07)
6/2006 thru 6/2007 Data Extracted from NCPS Database
-Actual Adverse Events -
OVER 300 REPORTS OF CLOSE CALLS NOT SHOWN
Number of Reports Submitted to NCPS
0
9
19
Towels
Sponges
Sharp, Instrument, Other
Note: Over 90% of reports (n=~400)
in this time period are close calls or
other no-harm incidents!
39. 40
Retained Sponges & Count Status
Retained Surgical Sponges (Only)
2000-2005
Final Counts
unclear, 17,
33%
No Counts
done, 3, 6%
Final Count
Incorrect, 12,
23%
Final Count
Correct, 20,
38%
40. 41
Retained Items & Count Status
All Retained Items & Count Status, 2000-2005
Incorrect Count,
12, 18%
Correct Count,
21, 33%
No Count (count
possible), 11,
17%
Count Status
Unclear, 17, 26%
Count
Impossible, 4,
6%
41. 42
Retained Items vs. Retained
Surgical Items: More Work Needed
• Sponges, clamps, and towels are “surgical
items”…
• But how about…
– miscellaneous “lines” and parts of lines and
catheters, blade of urethratome, “wires”, outflow
cannula, distal segment of “mediport”, etc.
– Many new reports of retained items are not
“classic” retained surgical items, i.e., not items
accidentally “left in” after surgery
42. 43
Tentative Take-Home Points
• Reporting of retained items increased after
Directive, especially reporting of unusual items,
as well as miscounts, close calls, and other no-
harm incidents
• Reporting of retained sponge actual adverse
events did not increase as other reporting
increased immensely.
• A minority of countable retained items resulted
from situations in which their count was certainly
correct.
– Incorrect counts should be taken very seriously.
• Another “methodical wound exploration” and a
dedicated radiograph when count is wrong (i.e.,
unreconciled)…
44. 45
Textbook Human Factors
• Yes, there is a textbook.
– mine was in it’s 5th edition in 1987
• Established after World War II
• It’s usually taught in the Industrial
Engineering department
– Sometimes by unusual engineers
– Sometimes by practical psychologists
– Or anthropologists who decided they needed
to learn something that pays
45. 46
From Sanders and McCormick
• Human factors focuses on human beings and
their interaction with products, equipment
facilities, procedures, and environments used in
work and everyday living.
• Human factors seeks to change the things that
people use [rather than changing the people that
use the things] to better match human
capabilities, limitations, and needs.
46. 47
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
47. 48
Safety & Human Error:
Cornerstones
• People Don’t Come to Work to Hurt
Someone or Make a Mistake
• Must Keep Asking “Why?”
48. 49
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.
58. 59
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
63. 64
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).
65. 66
Redundancy vs. Double-check
in Spelunking (Caving)
• Two choices of equipment
1. One flashlight batteries
checked twice
2. One flashlight and one
headlamp
WHICH ACTION IS STRONGER?
66. 67
Don’t Forget:
Action Assessment
• Characteristics of Actions
– Temporary vs. Permanent
– Procedural vs. Physical
• Action Evaluation
– Process
– Outcome
68. 69
Closing Thoughts
• Counting reports is not the objective,
identifying local vulnerabilities is…
– Analysis, Action, & Feedback Matter
• Prevention NOT Punishment
– Do not drive down reporting of incidents and
problems and declare success
• Cultural change is the key…
• Safety is the Foundation Upon
which Quality is Built
69. 70
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???
70. 71
Why Bother?
1. The Problem is Real
2. We Can All Do Things to Make it Better
Really believing and communicating
these 2 points fosters a “culture of
safety” and a “culture change”.
Example: MADD, Seatbelt laws, applying
research, modifying roads, etc., decreased
auto accident death rate 75% over 40 years.
71. 72
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
“They say that time changes things, but you
actually have to change them yourself”
- Andy Warhol