On the CUSP: STOP BSI The Science of Improving Patient Safety

1. On the CUSP: STOP BSIThe Science of Improving Patient Safety

2. Immersion Call Overview Week 1: Project overview Week 2: Science of Improving Patient Safety Week 3: Eliminating CLABSI Week 4: The Comprehensive Unit-Based Safety Program (CUSP) Week 5: Building a Team Week 6:Physician Engagement

3. Learning 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

4. The Marvel of Modern Medicine

6. RAND Study Confirms Continued Quality Gap 1. McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.

7. The Problem is Large • In U.S. Healthcare system • 7% of patients suffer a medication error 2 • On average, every patient admitted to an ICU suffers an adverse event 3,4 • 44,000- 98,000 people die in hospitals each year as the result of medical errors 5 • Nearly 100,000 deaths from HAIs 6 • Estimated 30,000 to 62,000 deaths from CLABSIs 7 • Cost of HAIs is $28-33 billion 7 • 8 countries report similar findings to the U.S. 2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995 3. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995. 4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997. 5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999. 6. Klevens M, Edwards J, Richards C, et al., PHR, 2007 7. Ending Health Care-Associated Infections, AHRQ, 2009.

9. How Can These Errors 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

10. Understanding the Science of Safety

11. How Can We Improve?Understand 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 blame

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

14. System Factors Impact Safety Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics 10. Adapted from Vincent C, Taylor- Adams S, Stanhope N., BMJ, 1998.

15. Evidence Regarding the Impact of ICU Organization on Performance • Physicians11 • Nurses12 • Pharmacists13 11. Pronovost P, Angus D, Dorman T, et al., JAMA, 2002. 12. Pronovost P, Dang D, Dorman T, et al., ECP, 2001. 13. Pronovost P, Jenckes M, Dorman T, et al., JAMA, 1999.

16. Fatal Aviation Accidents per Million Departures 14. Statistical Summary of Commercial Jet Airplane Accidents, Aviation Safety Boeing Commercial Airplanes, July 2009.

17. Principles 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

18. Standardize

19. Line Cart Contents – 4 Drawers

20. Eliminate Steps

21. Create Independent Checks

22. 2 Year Results from 103 ICUs 15. Pronovost P, Needham D, Berenholtz S et al., N Engl J Med, 2006.

23. Principles of Safe Design Apply to Technical and Team Work

24. Basic Components and Process of Communication 16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.

25. ICU Physicians and ICU RN Collaboration % of respondents reporting above adequate teamwork 17. ICUSRS Data from Needham D, Thompson D, Holzmueller C, et al., Crit Care Med, 2004.

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

27. Systems • 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 physician, one room

28. Teams Make Wise Decisions When There is Diverse and Independent Input • Wisdom of Crowds • Alternate between convergent and divergent thinking • Get from the dance floor to the balcony level 18. Heifetz R, Leadership Without Easy Answers,1994.

29. Don’t Play Man Down When you feel something say something

30. Recap • Develop lenses to see systems • Work to standardize one process • Infuse these principles of standardization and independent checks in other processes • Don’t play man down

31. Action Items • Have all members of the CUSP/CLABSI Team view the Science of Improving Patient Safety video • Put together a roster of who on your unit needs to view the Science of Safety video • Develop a plan to have all staff on your unit view the Science of Improving Patient Safety video • Assess what technologies you have available for staff to view • Identify times for viewing it (e.g., staff meetings, individual admin hours)

33. Works Consulted • McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348 (26): 2635-45. • Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. JAMA. 1995;274(1):29-34. • Donchin Y, Gopher D, Olin M, et al., A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 23:294-300,1995. • Andrews LB, Stocking C, Krizek T, et al., An alternative strategy for studying adverse events in medical care. Lancet. 349:309-313,1997. • Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington, DC: National Acad Pr; 1999. • Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. PHR.122:160-166,2007. • Ending Health Care-Associated Infections, AHRQ, Rockville,MD, 2009. http://www.ahrq.gov/qual/haicusp.htm. • Pronovost P, Wu A, Sexton J, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med. 2004;140(12):1025-1033. • Reason J, Hobbs A. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000. • Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998; 316: 1154–7. • Pronovost P, Angus D, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151-2162. • Pronovost P, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Effective clinical practice: ECP. 2001;4(5):199-206.

34. Works Consulted • Pronovost P, Jenckes M, Dorman T, et al. Organizational characteristics of intensive care units related to outcomes of abdominal aortic surgery. JAMA. 1999;281(14):1310–7. • Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations 1959-2008. Boeing News Releases/Statements. July 2009. Aviation Safety Boeing Commercial Airplanes, Web. 21 Jan 2010. <www.boeing.com/news/techissues/pdf/statsum.pdf>. • Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related bloodstream infections in the ICU. New Engl J Med. 2006;355(26):2725-32. • Dayton E, Henriksen K. Communication Failure: Basic components, contributing factors, and the call for structure. Jt Comm J Qual Patient Saf. 2007; 33(1): 34-47. • Needham D, Thompson D, Holzmueller C, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004;32:2227-33. • Heifetz R, Leadership Without Easy Answers, President and Fellows of Harvard College,1994.