Patient Safety

1
Patient Safety

• Prevention of Medical Errors

2
Why are we here?

• Concern over incidence of Medical Errors
• IOM Report (1999)
• To Err is Human, Building a Safer Healthcare
  System
• Statistics
• 44,000 98,000 Hospital deaths due to medical
  error each year

3
Why are we here?

• To commit to paying greater attention to the
  problem
• We make a difference one at a time
• To evaluate current approaches
• To build better systems to reduce the incidence
  of error

4
Why are we here?

• 2001 FL Legislative response
• FS 456.013
• Mandates 2 hour course for ALL health care
  providers as part of licensure and renewal
  process
• Course shall include the study of
• root-cause analysis
• error reduction
• error prevention
• patient safety

5
Why are we here?

• FL BON Requirement
• 64B9-5.011
• Continuing Education on Prevention of Medical
  Errors

6
FL BON Requirement

• Subject Areas
• Factors that impact the occurrence of medical
  errors
• Recognizing error-prone situations
• Processes to improve patient outcomes
• Responsibilities for reporting
• Safety needs of special populations
• Public education

7
Definitions

• Error (IOM report)
• The failure of a planned action to be completed
  as intended or the use of a wrong plan to achieve
  an aim
• Error of Execution
• Error of Planning

8
Definitions

• Adverse Events
• Injury caused by medical management rather than
  underlying disease condition
• Unpreventable
• Preventable

9
Definitions

• Medical Error
• Preventable adverse events with our current state
  of medical knowledge
• Not defined as intentional act of wrongdoing
• Not all rise to level of medical malpractice or
  negligence

10
Reporting Requirements

• Florida Law requires all licensed facilities to
• Have Internal Risk Management and incident
  reporting system
• Report Serious Adverse Events to
• AHCA Agency for Health Care Administration

11
Joint Commission

• National organization
• Mission to improve the quality of care in
  healthcare institutions
• Provides Accredited status to healthcare
  facilities

12
Joint Commission

• Defines Sentinel Event
• An unexpected occurrence involving death of
  serious physical or psychological injury or risk
  thereof

13
Joint Commission

• Sentinel events subject to review by Joint
  Commission
• an event resulting in unanticipated death or
  major permanent loss of function not related to
  the underlying condition or if the event is one
  of the following

14

• Suicide in setting with 24 hour care or within 72
  hours of discharge
• Unanticipated death of a full-term infant
• Abduction of any patient
• Discharge of infant to wrong family
• Rape
• Hemolytic Transfusion Reaction involving blood
  group incompatibilities

15
Joint Commission

• Requires
• Process in place to recognize sentinel events
• Credible root cause analysis
• Focus on systems not individuals
• Risk reduction strategies
• Internal corrective action plan
• Measure effectiveness of process
• System improvements to reduce risk

16
Root Cause Analysis

• Goal-directed, systematic process
• uncovers basic factors that contribute to medical
  error
• Focuses primarily on systems and processes and
  not individuals
• Product of root cause analysis is an action plan
  to reduce risk of similar future events

17
Root Cause Analysis

• Gather facts
• Assemble team
• Determine sequence of events
• Identify causal factors
• Select root causes
• Take corrective action and follow-up plan

18
Joint Commission

• Sentinel Event Statistics
• Type
• Setting
• Outcome
• Root Causes
• And more
• Sentinel Event Alerts
• Periodic publication
• Sharing information
• To share information
• To prevent medical errors/adverse events
• Website http//www.jointcommission.org/

19
Sentinel Events by Type Dec. 31, 2006

• 1. Wrong Site Surgery (13.1)
• 2. Patient Suicide (12.8)
• 3. Op/Post-op Complication(12.1)
• 4. Medication Error (9.5)
• 5. Delay in Treatment (7.4)
• 6. Patient Fall (5.5)
• 7. Patient death/injury in restraints
  (3.8)

20
Sentinel Events by Setting Dec. 31, 2006

• 1. General Hospital (67.9)
• 2. Psychiatric Hospital (10.8)
• 3. Psych unit in general hosp. (4.9)
• 4. Behavioral health facility (4.6)
• 5. Emergency Dept. (3.9)
• 6. Long Term Care Facility (3.0)
• 7. Ambulatory Care (2.7)

21
Root Causes of ALL Sentinel Events 1995-2005

• 1. Communication
• 2. Orientation / Training
• 3. Patient Assessment
• 4. Staffing
• 5/6. Availability of Info
• Competency / Credentialing
• 7. Procedural compliance
• 8. Environmental Safety / Security

22
Root Causes of ALL Sentinel Events - 2006

• 1. Communication
• 2. Patient Assessment
• 3. Leadership
• 4. Procedural Compliance
• 5. Environ. Safety / Security
• 6. Competency / Credentialing
• 7. Orientation / Training
• 8. Availability of Info

23
Root Causes Wrong Site Surgery 1995-2004

• 1. Communication
• 2. Orientation / Training
• 3. Procedural compliance
• 4. Availability of Info
• 5. Patient Assessment
• 6. Leadership
• 7. Competency / Credentialing
• 8. Organizational Culture

24
Root Causes Wrong Site Surgery 2005

• 1. Communication
• 2. Procedural compliance
• 3. Leadership
• 4. Competency / Credentialing
• 5. Availability of Info
• 6. Organizational Culture
• 7. Orientation / Training
• 8. Patient Assessment Care Planning

25
Root Causes Wrong Site Surgery 2006

• 1. Procedural compliance
• 2. Communication
• 3. Leadership
• 4. Availability of Info
• 5. Competency / Credentialing
• 6. Orientation / Training
• 7. Patient Assessment Organizational Culture
• 8. Environmental Safety / Security

26
Root Causes Suicide 1995-2004

• 1. Environmental Safety / Security
• 2. Patient Assessment
• 3. Orientation / Training
• 4. Communication
• 5. Availability of Information
• 6. Continuum of Care
• 7. Competency / Credentialing
• 8. Staffing levels

27
Root Causes Suicide 2005

• 1. Patient Assessment
• 2. Environmental Safety / Security
• 3. Communication
• 4. Orientation / Training
• 5. Competency / Credentialing
• 6. Availability of Information
• 7. Leadership
• 8. Procedural Compliance Continuum of Care

28
Root Causes Op/Post-op Complications 1995-2004

• 1. Orientation / Training
• 2. Communication
• 3. Procedural compliance
• 4. Patient Assessment
• 5. Staffing
• 6. Competency / Credentialing Availability of
  Info
• 7. Care Planning
• 8. Leadership

29
Root Causes Op/Post-op Complications 2005

• 1. Communication
• 2. Patient Assessment
• 3. Procedural compliance
• 4. Care Planning
• 5. Availability of Info
• 6. Organizational Culture
• 7. Competency / Credentialing
• 8. Leadership

30
Root Causes Medication Error 1995-2004

• 1. Communication
• 2. Orientation / Training
• 3. Competency / Credentialing
• 4. Staffing
• 5. Procedural Compliance
• 6. Availability of Info
• 7. Patient Assessment
• 8. Environmental Safety Security Leadership

31
Root Causes Medication Error 2005

• 1. Communication
• 2. Procedural Compliance
• 3. Competency / Credentialing
• 4. Leadership Patient Assessment Orientation
  / Training
• 5. Environ. Safety/Security
• 6. Organizational Culture Staffing

32
Root Causes Delay in Tx. 1995-2004

• 1. Communication
• 2. Patient Assessment
• 3. Continuum of Care
• 4. Orientation / Training
• 5. Availability of Info
• 6. Competency / Credentialing
• 7. Staffing
• 8. Care Planning

33
Root Causes Delay in Tx. 2005

• 1. Communication
• 2. Patient Assessment
• 3. Procedural Compliance
• 4. Continuum of Care / Availability of Info
• 5. Care Planning / Leadership
• 6. Competency / Credentialing

34
Root Causes Patient Falls 1995-2004

• 1. Orientation/Training
• 2. Communication
• 3. Patient Assessment
• 4. Environmental Safety / Security
• 5. Care planning
• 6. Leadership Staffing
• 7. Competency / Credentialing
• 8. Availability of Info

35
Root Causes Patient Falls 2005

• 1. Patient Assessment
• 2. Communication
• 3. Environmental Safety / Security
• 5. Leadership
• 6. Procedural Compliance
• 7. Orientation / Training Care Planning
• 8. Availability of Info Competency /
  Credentialing

36
Root Causes Restraint Injury/Death 1995-2004

• 1. Orientation / Training
• 2. Patient Assessment
• 3. Communication
• 4. Care Planning
• 5. Staffing
• 6. Competency / Credentialing
• Availability of Info.
• 7. Environmental Safety / Security
• 8. Procedural Compliance
• 9. Continuum of Care

37
Root Causes Restraint Injury/Death 2005

• 1. Communication Patient Assessment
• 2. Environmental Safety / Security
• 3. Orientation / Training Competency /
  Credentialing
• Availability of Info.
• 4. Procedural Compliance Care Planning
• 5. Leadership

38
Now What?

• Learn from Knowledge of
• Sentinel Event Statistics
• Root Causes
• Make Prevention a Priority
• Make changes
• Improve patient safety
• Follow Joint Commission recommendations
• Sentinel Event ALERT

39
Wrong Site Surgery Prevention

• Clearly mark the operative site and involve the
  patient in the process
• Require oral verification of the correct site in
  the OR by each member of the surgical team
• Develop verification checklist that includes all
  documents

40
Wrong Site Surgery Prevention

• Surgical teams consider taking a time out to
  verify patient, site, procedure using active
  communication
• Ensure ongoing monitoring that verification
  process is followed

41
Inpatient Suicide Prevention

• Identify/Remove/Replace non-breakaway hardware
• Weight test all breakaway hardware
• Revise procedures for contraband detection and
  include family and friends in process

42
Inpatient Suicide Prevention

• Standardize suicide risk assessment/reassessment
  procedures
• Enhance staff orientation and education
• Ensure consistency in implementation of
  observation procedures

43
Inpatient Suicide Prevention

• Redesign, retrofit, or introduce security
  measures
• Revise information transfer procedures
• Implement education for family and friends
  regarding suicide risk factors

44
Op/Post-Op Complications Prevention

• Improve staff orientation and training
• Educating and counseling physicians
• Revising credentialing and privileging procedures
• Clearly defining expected channels of
  communication

45
Op/Post-Op Complications Prevention

• Standardizing procedures across settings of care
• Revising the competency evaluation process.
• Monitoring consistency of compliance with
  procedures

46
Op/Post-Op Complications Prevention

• Implementing a teleradiology program
• Correct placement of catheters and tubes should
  be verified with a test or x-ray

47
Medication ErrorsPrevention

• Recognize High Alert Meds
• Insulin
• Opiates and Narcotics
• Injectable Potassium Chloride
• Intravenous Anticoagulants
• Sodium Chloride Solutions above 0.9

48
Medication ErrorsPrevention

• Follow the 5 (6) Rights of Medication
  Administration
• Use 2 identifiers
• Limit and institute Read Back policy of all
  verbal orders
• Standardize Abbreviations

49
Medication ErrorsPrevention

• Joint Commission abbreviations on the DO NO USE
  list
• U for Unit write unit
• IU for International Unit write international
  unit
• QD, QOD Write daily or every other day

50
Medication ErrorsPrevention

• Joint Commission abbreviations on the DO NO USE
  list
• Trailing zero (X.0 mg.) write (X mg.)
• Lack of leading zero (.X mg) - write (0.X mg)
• MS, MSO4, MgSO4 - write morphine sulfate,
  magnesium sulfate

51
Medication ErrorsPrevention

• Expand the DO NOT USE list
• ug for microgram write mcg.
• H.S. write out half strength or at bedtime
• T.I.W. write 3 times weekly
• S.C. of S.Q. write Sub-Q or subQ
• D/C write discharge or discontinue
• cc. write ml.

52
Medication ErrorsPrevention

• Remove Potassium Chloride/Phosphate from floor
  stock
• Standardize and limit drug concentrations
• Move drug preparation off units and use
  commercially available premixed IV solutions

53
Medication ErrorsPrevention

• Do not store heparin and insulin next to each
  other
• System plan for sound alike and look alike meds
• Educate staff about hydromorphone and morphine
• Implement PCA protocols that involve
  double-checks of drug, pump setting and dosage

54
Medication ErrorsPrevention

• Use only IV pumps with set-based free flow
  protection
• Limit the variety of pumps available in the
  organization
• Provide or ask for both brand and generic names
  of drugs for medication orders

55
Medication ErrorsPrevention

• Provide the generic and brand name on all
  medication labels
• Provide the patient with written information
  about their drugs which includes the brand and
  generic names

56
Medication ErrorsPrevention

• Patient controlled analgesia by proxy
• Develop criteria for selecting appropriate
  patients to receive PCA
• Carefully monitor patients
• Teach staff, patients and family members about
  dangers of pressing button for patient

57
Medication ErrorsPrevention

• Using medication reconciliation to prevent errors
• Process for obtaining and documenting complete
  list of current medications on admission/transfer/
  discharge
• Create a process for reconciling medications at
  all interfaces of care

58
Delay in TreatmentPrevention

• Implement processes and procedures designed to
  improve the timeliness, completeness and accuracy
  of staff-to-staff communication
• Implement face to face interdisciplinary
  change-of-shift debriefings
• Reduce verbal orders and require read-back
  policy

59
Patient FallsPrevention

• Standardize Assessment of Risk for Falls
• Ongoing reassessment regarding risk
• Orient staff to formal fall prevention protocols

60
Restraint Injury/DeathPrevention

• Redouble efforts to reduce use of physical
  restraints
• Enhance staff education regarding alternatives to
  physical restraints
• Develop structured procedures for consistent
  application of restraints

61
Restraint Injury/DeathPrevention

• Continuously observe patients in restraints
• If patient is restrained in supine position,
  ensure head is free to rotate and HOB is
  elevated.
• Do not restrain a patient in bed with unprotected
  split side rails

62
Creating a Culture of Safety

• Understand human factors and system flaws
• Make safety everyones responsibility
• Report errors or near misses to decrease future
  error
• Actively seek improvement to process

63
Creating a Culture of Safety

• Know and understand the six major categories of
  negligence
• Failure to follow standard of care
• Failure to use equipment in proper, responsible
  manner
• Failure to communicate, including inadequate
  transfer of information

64
Creating a Culture of Safety

• Know and understand the six major categories of
  negligence
• Failure to document properly
• Failure to accurately assess and monitor
• Failure to act as an advocate for the patient

65
Patient Responsibilities

• Be an active member of the healthcare team
• Make sure doctors know about all medicines you
  are taking
• Make sure doctors know about your allergies or
  adverse reactions
• When the doctor writes a prescription be sure you
  can read it

66
Patient Responsibilities

• Ask for information about your medicine that you
  can understand
• When pick up medicine from pharmacy, ask if this
  is the medicine your doctor prescribed
• If you have any questions about the directions,
  ask!

67
Patient Responsibilities

• Choose a hospital at which many patients have had
  the surgery or procedure you need
• Ask care providers if they have washed their
  hands
• Prior to surgery, make sure that you, your doctor
  and your surgeon all agree on what is to be done

68
Patient Responsibilities

• Speak up if you have questions
• Ask a family member or friend to be there with
  you to be your advocate
• Learn about your condition and treatments by
  asking your doctor and using other reliable
  resources

69
2007 National Patient Safety Goals

• Improve the accuracy of patient identification
• Improve the effectiveness of communication among
  caregivers
• Improve the safety of using medications
• Reduce the risk of health care-associated
  infections.

70
2007 National Patient Safety Goals

• Accurately and completely reconcile medications
  across the continuum of care
• Reduce the risk of patient harm resulting from
  falls
• Reduce the risk of influenza and pneumococcal
  disease in institutionalized older adults
• Reduce the risk of surgical fires

71
2007 National Patient Safety Goals

• Implementation of applicable NPSG and associated
  requirements by components and practitioner sites
• Encourage patients active involvement in their
  own care as a patient safety strategy
• Prevent health care-associated pressure ulcers
• The organization identifies safety risk inherent
  in its patient population.