Moving Forward 21st Annual Institute

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Moving Forward 21st Annual Institute
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Background - IOM Report

• The risk of dying as a result of medical error
  far surpasses the risk of dying in an airline
  accident.
• Death on Domestic Flights - 1 in 8,000,000 flights

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Background - IOM Reportcontd

• Death in Hospitals from Medical Errors
• 1 in 343 Admits to 1 in 764 Admits
• Adverse Events in Hospitals
• 1 in 27 Admits to 1 in 34 Admits

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The Patient Safety Learning Lab

• Top 10 Recommendations for Facility Design
• FMEA at each design stage
• Standardization of Location
• Involve patients/families in design process
• Establish a checklist for current/future design
• Critical information close to the patient
• Noise reduction
• Adaptive systems for function in the future
• Articulate a set of principles for measurement
• Equipment planning Day 1
• Begin mock-ups on Day 1

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Design Recommendations

• Latent Conditions
• Noise reduction
• Scalability, adaptability, flexibility
• Visibility of patients to staff
• Patients involved with their care
• Standardization
• Automate where possible
• Minimize fatigue
• Immediate accessibility of information, close to
  the point of service
• Minimize Handoffs
• Minimize Patient Movement

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Design Recommendations, cont

• Active Failures
• Operative/Post-Op Complications/Infections
• Events Relating to Medication Errors
• Deaths of Patients in Restraints
• Inpatient Suicides
• Transfusion Related Events
• Correct Tube-Correct Connector-Correct Hole
• Patient Falls
• Deaths Related to Surgery at Wrong Site
• MRI Hazards

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Process Recommendations

• Matrix Development (post Learning Lab)
• FMEA at each stage of design
• Patients/Families involved in design process
• Equipment planning day 1
• Mock-ups day 1
• Design for the vulnerable patient
• Articulate a set of principles for measurement
• Establish a checklist for current/future design

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Creating a Culture of Safety

• Shared Values and Beliefs about Safety within the
  Organization
• Always Anticipating Precarious Events
• Informed Employees and Medical Staff
• Culture of Reporting
• Learning Culture
• Just Culture
• Blame-Free Environment Recognizing Human
  Infallibility
• Physician Team Work
• Culture of Continuous Improvement
• Empowering Families to Participate in Care of
  Patients
• Informed Activated Patient

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Our Patient Safe Room