Understanding Patient Safety

1. Understanding Patient Safety Presented by Dr. Redouane Bouali Canadian Patient Safety Institute (CPSI) June 10th, 2010

2. To provide national leadership in building and advancing a safer Canadian health system Mission Vision • We envision a Canadian health system where: • Patients, providers, governments and others work together to build and advance a safer health system; • Providers take pride in their ability to deliver the safest and highest quality of care possible; and • Every Canadian in need of healthcare can be confident that the care they receive is the safest in the world.

3. A Sad Story Noisy place!! KCI bed Rep He interrupted the nurses sign off and asked if he can bring his bed. The nurses suddenly realized that the patient was in cardiac arrest..... It was too Late!!! • 65 years patient, in ICU being dialyzed • Two nurses signing over • Patient experienced an arythmia • No body noticed the ECG strip.... • No body could hear the alarm Bell

4. Nosocomial infection outbreak • Burn Unit • Experienced outbreak • MRSA and VRE Serious concerns.... Security control at the front door Hand Washing Mandatory!!!! • Line infection!!!! • A BIG CONCERN!!!

5. Results: Catheter infections

6. A very poor communication • 24 years old man medical student • Visited ER for abdominal pain • Discharged after 36 hours with diagnosis of Gastritis. • Patient went again to the ER for the same problem • Patient insisted to go home because he had important test to do at the University • Patient went to his hometown... Operated the same night for Appendicitis (After 10 days!!!)

7. Poor communication • Patient two days post op when was authorized to go home , while walking in the parking crashed!!!! • Died after 2 hours of CPR • Parents devastated asked several times for an explanation (head of Surgery, head of Emergency, in the two hospitals ....) • Finally after few months they went to the Media,,,,,,

8. Overview • Introduction to Patient Safety • Systems vs. Person Approach • The Safety Competencies • The Role of the Clinician, Team and Patient • Strategies to Improve Patient Safety • Conclusion

9. Background • The “Quality in Australian Health Care Study” (1995) • The U.S. Institute of Medicine published the report “To Err is Human” (1999) • The British Report, “An Organization with a Memory” from the National Health Service (2000) • National Steering Committee on Patient Safety’s “Building a Safer System” (2002) • The Canadian Adverse Events Study (2004)

10. Canadian Adverse Events Study Adverse Event (AE)is defined as: “an unintended injury or complication thatresults in disability at the time of discharge, death or prolonged hospital stay and that is caused by health care management rather than by the patient’s underlying disease process.” Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J et al. (2004). The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada. CMAJ, 170(11), 1678-1686.

11. Findings: 3,745 charts reviewed ~7.5% of hospital admissions involve adverse event; 37% of adverse events preventable Extrapolation: Of ~2.5 million hospital admissions in Canada in 2000… …185,000 experienced 1 or more adverse events …70,000 of the 185,000 were determined to be preventable …between 9,000 and 24,000 deaths due to adverse events could have been prevented Canadian Adverse Events Study

12. Canadian Adverse Events Study 9-24,000 1,100,000 Deaths among patients with preventable adverse events Extra hospital days associated with adverse events

13. Canadian Institute for Health Information (2004) One in ten adults contract infection in hospital. One in ten patients receive wrong medication or wrong dose. More deaths after experiencing adverse events in hospital than deaths from breast cancer, motor vehicle and HIV combined. What We Know

14. Epidemiology of Harm World Health Organization. (2004). World Alliance for Patient Safety: Forward programme 2005. Geneva, Switzerland: World Health Organization. Retrieved from http://www.who.int/patientsafety/en/brochure_final.pdf

16. Definitions Patient Safety - The reduction and mitigation of unsafe acts within the healthcare system through the use of best practices shown to lead optimal patient outcomes. (Canadian Patient Safety Dictionary, 2003) Adverse Events - Unintended injuries or complications that are caused by health care management, rather than the patient’s underlying disease, and that lead to death, disability at the time of discharge, or prolonged hospital stays. (Baker et al., 2004) Harm - An outcome that negatively affects a patient’s health and/or quality of life. (Canadian Disclosure Guidelines, 2008)

17. Adverse Events Delayed or missed diagnoses Medication errors Wrong side surgery Wrong patient surgery Equipment failure Patient identity Transfusion errors Mislabeled specimen Patient/resident falls Time delay errors Laboratory errors Radiology errors Procedural error Lost, delayed, or failures to follow up reports Retention of foreign object following surgery Contamination of drugs, equipment Intravascular air embolism Failure to treat neonatal hyperbilirubinemia Stage lll or lV pressure ulcers acquired after admission Wrong gas delivery Deaths associated with restraints or bedrails Sexual or physical assault

18. Adverse Events vs. Critical Incidents • Not all negative patient outcomes are “adverse events” • Not all adverse events • are “critical incidents” Negative Outcomes Adverse Events Critical incidents are the most serious preventable adverse events. Critical Incidents

19. What Patient Safety Is and Is Not It is NOT what most of us were thinking about 10 years ago It is NOT what ‘we have always done’ It is the most significant change in the healthcare system in over a century It is a new applied science It has forever changed the face of modern healthcare

20. Risky Activities(Adapted by Dr. Philip Hebert) Offshore Industry Coal Mining timber truckers Rock Climbing for 25 hrs construction Bungee Jumping 15,000 deaths/yr Dangerous (>1/1000) Regulated Ultra-safe (<1/100K) 100,000 Hospitalization 10,000 Driving Total Lives Lost per year 1,000 Commercial airlines Firearms 100 10 Scuba diving 1 10 100 1,000 10,000 100,000 1,000,000 10,000,000 Number of encounters for each fatality

21. The Challenge In health systems, the challenge is to change the environment from one of crisis and blame to that of learning and improvement. Emory Center on Health Outcomes & Quality Partnership for Health & Accountability, July 2004

22. Determinants of Adverse Events The System The People

23. Most problems are found in processes, not in people.

24. A system can be described as: A grouping of components, such as resources and organization (structure) that act together (process), to achieve a particular result (outcome). (Canadian Patient Safety Dictionary, 2003) “Clearly certain structure is needed; and equally clearly, there is no way to change outcome except through changing process, since outcome ‘tells on’ process.” Slee VN, Slee DA & Schmidt HJ (1996). Slee’s Health Care Terms, 3rd edition. St. Paul, MN: Tringa Press. A System Perspective

25. Sources of System Error Overall culture Education / training / experience System design / engineering Resource availability Demand / volume Throughput impedance Shift-work schedules

26. The Systems Approach Reason, J., (2000), BMJ(320), 768.

27. The Systems Approach “…though we cannot change the human condition, we can change the conditions under which humans work.” Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770.

28. The Person Approach Historically focused on individual performance and not system issues Front line staff often not involved in the review of an adverse event Partial or incomplete “solutions” that do not fully resolve the underlying cause and leave the organization vulnerable to reoccurrence of the event Fear of reprisals drives important information underground

29. What about professional accountability? Does a “system” approach mean that individual practitioners are not accountable for their actions?

30. Sources of Personal Error • Skill-based errors • Rule-based errors • Knowledge-based error

31. The Person Approach “Incompetent people are 1% of the problem. The other 99% are good people trying to do a good job who make very simple mistakes and it's the processes that set them up to make these mistakes.” Dr. Lucian Leape, Harvard School of Public Health

32. Person vs. Systems Approach Person Errors are the result of human failures Humans generally perform flawlessly Perfect performance is the expectation Use retraining and punishment to root out “bad apples” • Systems • Begin with the premise that anything can and will go wrong • Don’t expect humans to perform perfectly • Design systems accordingly in a proactive way • Collective preoccupation with possibility of failure

34. The Safety Competencies Domain 1 Contributing to a culture of patient safety Definition: A commitment to applying core patient safety knowledge, skills and values to everyday work 34

35. Shared Accountability-Just Culture- “…it is about creating a reporting environment where staff can raise their hand when they have seen a risk or made a mistake…..where risks are openly discussed between managers and staff.” “…while we as humans are fallible, we do generally have control of our behavioural choices.” “…good system design and good behavioural choices of staff together produce good results. It has to be both.” Marx D, Comden SC, Sexhus Z (2005). Our inaugural issue – in recognition of a growing community.The Just Culture Community News and Views, 1(1). 35

36. Safety Culture Excessive blame prevents recognition of error, impedes learning and effective action to improve safety.

37. Safety Culture • “Join us in converting a culture of blame that hides information about risk and error into a culture of safety that flushes out information to prevent patient injuries.” (Leape et al, 1998) • “A somewhat lethal cocktail of impatience, scientific ignorance and naïve optimism may have dangerously inflated our expectations of safety culture.” (Cox & Flin, 1998)

38. Culture as Awareness • Awareness of error and harm • Willingness to discuss openly • Open and fair culture • Open disclosure • Essential foundations

39. Culture Teamwork All focused on accomplishment of mutual goals Aim for high-quality performance When something goes wrong… The focus is on what happened, rather than “who did it” Atmosphere of how do we find the issues / weaknesses and solve them

40. The Safety Competencies Domain 2 Work in teams for patient safety Definition: Working within interprofessional teams to optimize patient safety 40

41. Teamwork in Healthcare • Healthcare must “establish team training programs for personnel in critical care areas . . . using proven methods such as the crew resource management training techniques employed in aviation” (Kohn et. al, 2000)

42. The Safety Competencies Domain 3 Communicate effectively for patient safety Definition: Promoting patient safety through effective health care communication 42

43. Communication / Team WorkWhy is it critical? Nearly all instances of unexpected adverse events involve communication failures Joint Commission sentinel event data -more than 2400 serious case analysis revealed communication failures were root cause in over 70% 43

44. The Safety Competencies Domain 4 Manage safety risks Definition: Anticipating, recognizing and managing situations that place patients at risk 44

45. Clinicians Create Safety • Err on the side of safety – speak up and ask questions. Be safe first and brave afterwards. • Be obsessive about hand washing. Be very aware of why we need to do this and less irritated about the time it takes. • Have enough humility to recognize when you are out of your depth. Be willing to ask for help and receive help. • Assess the situation and Be prepared to Complete the task.

46. Teams Create Safety • Make it clear what protocol or plan is being used. • Messages and communications are acknowledged and repeated by those who receive them. • Team members are aware of other’s actions and are ready to step in to support and assist. • Team members support and monitor each other. • Speak up when a patient is at risk.

47. Patients Create Safety • Speak up if you have questions of concerns, and if you don’t understand, ask again. It’s your body and your health, you have a right to know. • Pay attention to the care you’re receiving. Make sure you’re getting the right treatments and medications. Don’t assume anything. • Notice whether your caregivers have washed their hands. Don’t be afraid to remind them to do this.

48. The Safety Competencies Domain 5 Optimize human and environmental factors Definition: Managing the relationship between individual and environmental characteristics to optimize patient safety 48

49. Strategies to ImprovePatient Safety Hand hygiene Human factors engineering Safer Healthcare Now interventions Improved care for Acute Myocardial Infarction Prevention of central-line associated bloodstream infection Medication reconciliation (Acute care/Long-term care) Rapid response teams Prevention of surgical site infections Prevention of ventilator-associated pneumonia Antibiotic resistant organisms (MRSA) National collaborative on falls in long-term care Venous thromboembolism Governance for safety and quality 49

50. 10 Patient Safety Tips-Healthcare Professionals- Communication: • Introduce yourself to your patients and let them know that you invite them to bring any concerns to your attention • Don’t allow patient and family concerns to go unresolved • Listen! Listen! Listen! • Maintain Situational Awareness (be alert, follow your intuition) • Participate in the implementation of a common communication tool (e.g. SBAR)