N96: Patient Safety

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N96 Patient Safety

• Linda Cronenwett
• Dean and Professor

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N96

• When I found out we were having a class on
  patient safety, my immediate reaction was.
• My personal experiences with patient safety
  are..
• One reaction I had to the readings was

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Where Weve Been...

• Quality assurance
• Quality control
• Punishing workers for errors
• Acceptance of rising costs
• Professional knowledge Good quality

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Where We Are.

• Beginning efforts at continuous quality
  improvement
• Beginning to look to the system, not the person,
  for cause of errors
• Beginning understanding that higher quality costs
  less, not more

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Two World Views

• Micro-system accountability
• Care standardized to best evidence
• System as the source of error
• Process variation based on patient needs and
  preferences

• Individual accountability
• Professional autonomy
• Individual as source of error
• Process variation based on professional training
  and expertise

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Relative Focus of Nursing Education

• Professional knowledge
• Individual learning
• Individual consequences for error
• Disciplinary focus

• Systems knowledge
• Team/Group learning
• Learning from error
• Interdisciplinary/
• patient focus

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IOM 1999 Report To Err is Human

• Medical errors are a serious problem
• The cause is bad systems
• We are losing the publics trust
• We need to make safety a priority
• National - Health Care Systems
• Professions - Regulators
• Education

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The High-Risk Environment

• Complex, multi-component decisions
• Rapidly evolving, ambiguous situations
• Information overload
• Severe time pressure
• Adverse physical conditions
• Performance/command pressure

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Crossing the Quality Chasm (IOM, 2001)

• Six Aims
• Health care should be
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

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Crossing the Quality Chasm (IOM, 2001)

• Safety -- As safe in health care as in our homes
• Effectiveness -- Matching care to science
  avoiding overuse of ineffective care and under
  use of effective care
• Patient Centeredness -- Honoring the individual,
  and respecting choice
• Timeliness -- Less waiting for both patients and
  those who give care
• Efficiency -- Reducing waste
• Equity -- Closing racial and ethnic gaps in
  health status

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Crossing the Quality Chasm (2001) What Patients
Should Expect

• Rule 6 Safety
• Errors in health care will not harm you
• You will be safe in the care system

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Sources of Error

• 1. Active Failures
• Unsafe acts committed by physicians, nurses, and
  other staff in direct contact with patients
• James Reason

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Sources of Error

• 2. Latent Conditions
• The ongoing circumstances of daily practice that
  reduce the safety of patients
• We cant change the human condition, but we can
  change the conditions under which humans work
  
• James Reason

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Sources of Error

• Describe examples of latent conditions that might
  exist at the level of
• The individual practitioner
• The team
• The micro-system
• The organization
• The technology

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Sources of Error
Organization Priority Setting Finances Budget Po
licies Liability Info Systems
Micro-system Communication Supervision Handoffs H
armony Staffing Skill Mix Equipment
Individual Training Workload Protocols Fatigue
Patient
Staff
Active Failure
Latent Conditions
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When Large Systems Fail

• It is usually due to multiple faults that occur
  together

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Other Safety Terminology (Reason, 1990)

• Slip error of execution that is observable the
  right intention incorrectly executed
• Lapse error of execution that is not
  observable the right intention not executed
• Mistake wrong intention action proceeds as
  planned but fails to achieve intended outcome
  because the planned action was wrong

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Law of Stretched Systems (Woods and Cook,
2002)

• Under resource pressure, the benefits of
  change are taken in increased productivity,
  pushing the system back to the edge of the
  performance envelope

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Systemic Migration to Boundaries (Amalberti, 2002)
Expected safe space of action as defined by
professional standards
VERY UNSAFE SPACE
PERFORMANCE
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IOM Solutions

• Adverse event reporting systems
• Near miss reporting systems
• Checklists
• Forced functions
• Drug order entry systems
• Bar-coding
• Team/crew training
• Simulation

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Barriers to Reporting

• Legal
• Cultural
• Regulatory
• Financial
• Other

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Benefits of Analyses of Near Misses vs. Adverse
Events

• 3 300 times more common
• Fewer barriers
• Focuses on recovery
• Minimal hindsight bias
• Cheaper
• No blame (less blame)
• No legal problems

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Predictability of Error

• Active failures difficult to predict
• Latent conditions - may be identified and removed
  before they are transformed into accidents
• James Reason

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Creating a Safety Culture

• Informed culture people understand and respect
  the hazards they face
• Reporting culture a safety information system
  that collects, analyses, and disseminates
  knowledge gained from incidents and near misses
• Just culture - how an organization handles blame
  and punishment

J. Reason
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Safety Sciences

• Human factors
• Cognitive psychology
• Engineering
• Work group sociology

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Human Factors Science

• The ways in which the design of machinery,
  tools, and patient care settings can be altered
  to reduce the likelihood of errors

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Cognitive Psychology

• Example Short-term memory is highly fallible,
  especially when individuals are under stress
• Use checklists and protocols
• Standardize processes and equipment

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Engineering

• Work around a compensatory mechanism often
  employed by healthcare workers when dysfunctional
  work processes make it difficult or impossible to
  complete critical tasks
• Example Shutting off the alarms

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Engineering

• Force function making it impossible for
  an error to occur
• Example Removing potassium chloride from
  acute care units

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Work Group Sociology

• Authority gradient the inability to
  communicate honestly in perceived hierarchical
  situations

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Work Group Sociology

• Diffusion of responsibility no clear
  accountability for a task or work process

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Factors that Increase Risk of Error

• Greater complexity one component of the system
  can interact with others, sometimes in complex
  and invisible ways greater specialization
  multiple feedback loops
• Tightly coupled systems no slack or buffer
  between two items (y depends on x having been
  done) cant reorder sequence of production
  prevents errors from being intercepted

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Reducing Error in Complex, Tightly Coupled Systems

• Make them more reliable
• Build in more defenses against error
• Simplify and standardize processes
• Build in redundancy
• Develop backup systems

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Teamwork and Patient Care

• In most cases, clinicians cannot function on
  their own independent of a system.
• Patients with chronic conditions, in critical
  acute care, in geriatrics, and in care at the end
  of life necessitate smooth team functioning
  because of the complexity of their needs.

(Summit on Educating Health Professionals to
Improve Quality of Care, IOM)
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Teamwork and Error

• From Sasou and Reason (1999)
• While teamwork can detect and recover errors, it
  can also create errors

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Attitude Requirements in Teams

• Team orientation (morale)
• Collective efficacy
• Shared vision
• Team cohesion
• Interpersonal relations
• Mutual trust
• Collective orientation to the importance of
  teamwork

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Team Decision Making (From Salas,
Cannon-Bowers, Johnston, 1997)

• Each team member must understand
• The equipment (technology)
• The task and how to accomplish it
• The role the team member plays in the task, as
  well as the role of other team members

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Team Performance Shaping Factors (Sasou
Reason, 1999)

• Factors arising from a group of people working
  together on a common project or task
• Lack of communication
• Inappropriate task allocation
• Excessive authority gradient
• Over- trusting

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Failures to Detect Error (Sasou Reason,
1999)

• Team performance shaping factors exceed by 50
  all the performance shaping factors found in
  failures to detect
• Most common - Deficiency of communication
• If people do not have enough information through
  communication, they will not have any chance to
  detect either individual or shared errors

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Failures to Detect Error (Sasou Reason,
1999)

• Excessive authority gradients were often coupled
  with task criticality and high arousal in
  creation of errors
• If a decision maker is a senior team member and
  people are very tense, they may accept the
  seniors decision without evaluating its
  appropriateness (excessive belief, excessive
  professional courtesy, over-trust)

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Failures to Indicate or Correct Error Following
Detection (Sasou Reason, 1999)

• Most dominant factor Excessive authority
  gradient (24)
• Conclusion Only understanding what needs to be
  done and what is ones own responsibility
  overcomes the obstacles of authority gradient

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Analyses of Risk Cases and Closed Malpractice
Claims (n54) (Risser, Rice, Salisbury et
al, 1999)

• The average number of teamwork failures per case
  was 8.8 (range 1-32)
• The single teamwork failure most frequently cited
  as a primary contributor to clinical error was
  failure to cross-monitor - (35 of cases)

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Analyses of Risk Cases and Closed Malpractice
Claims (n54) (Risser, Rice, Salisbury et
al, 1999)

• Failures of four teamwork actions were the
  primary contributors in more than 20 of cases
• Identify protocol or plan and make it clear to
  everyone on team
• Advocate and assert a position or corrective
  action when patient at risk
• Prioritize tasks for patients
• Cross-monitor actions of team members

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Teams (vs. Crews)

• Duration is often open-ended
• Interpersonal relations are important
• Tools related to decision-making and conflict
  resolution are needed
• Members are selected with care
• Development of trust in individualized
  member-member ties lengthens the team formation
  process

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Crews (vs. Teams)

• Short-term groups are assembled from larger pools
• Members are trained for specific tasks with
  specific sets of tools
• Members fill slots in job network until their
  time is up may not see project through to
  completion
• Swift trust must be conferred presumptively

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Crews

• Psychological boundaries are weak no long term
  group identity
• The larger the pool from whom the members are
  drawn, the lesser the psychological ties among
  members
• Primary group identity resides with pools from
  which members are drawn - such as, professions

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Teams and Crews

• What differences among these work groups have
  implications for patient safety?
• What skills are needed for effective work in
  teams and crews?
• What implications are there for role autonomy and
  delegation if working in teams or crews?

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Other Safety Ideas

• Patient safety leadership walk rounds
• Team safety huddles/briefings
• Medication reconciliation
• Trigger reviews for adverse events
• Standardized protocols, such as for sliding scale
  insulin
• Patient care unit control of admissions

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Roles for Nursing Education

• Clinical teaching
• Faculty teach students how to learn from error
• Preceptors are chosen for their ability to role
  model
• Evidence-based practice
• Interdisciplinary collaboration
• Commitment to continuous learning and improvement

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Roles for Nursing Education

• Clinical teaching
• Clinical teaching sites are chosen because they
  are high-performing health care micro-systems
• Health professional students are oriented to
  their role in the micro-system and to the roles
  of others

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Possible Learning Activities

• Student Assignments
• Participate in at least one improvement team,
  critiquing roles and processes
• Assess a health care system using the Ten Rules
  after accompanying one patient and family during
  multiple health care encounters

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Possible Learning Activities

• Student Assignments
• Flow chart at least one process of care and apply
  principles of process improvement to suggest
  change
• Participate in one root cause analysis of a
  sentinel event or other error

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Other Learning Activities

• Student Assignments
• Write one paper that includes an analysis of the
  level of functioning of a team with whom student
  has practiced
• Write a self-assessment of a situation where
  communication did or did not take place across
  the authority gradient