TOOLS FOR PERFORMANCE IMPROVEMENT – Can the checklist BE the answer?

Institute of Medicine Report Consequences of Medical Errors: 44,000–98,000 annual deaths resulting from medical errors http://www.aorn.org

Institute of Medicine Report Consequences of Medical Errors: More Americans die from medical errors than from breast cancer, AIDS, or car accidents http://www.aorn.org

Institute of Medicine Report Consequences of Medical Errors: 7% of hospital patients experience a serious medication error http://www.aorn.org

Institute of Medicine Report Consequences of Medical Errors: Cost associated with medical errors is $8–29 billion annually http://www.aorn.org

Communication Failure is Leading Root Cause http://www.aorn.org

Communication Verbal or Written Sender Receiver Barriers http://www.aorn.org

Communication Barriers Noise and distractions Personality conflicts Complex nature of the information Fatigue due to inadequate staffing Time constraints Information overload

Communication failures Misinterpretation Misunderstanding Inattention Not remembering

RN Communication failures May involve: Medications Allergies Treatments Physicians orders

Ctic top 5 communication failures Current health status Current name and phone for Family/Emergency Contact Current Med List (including date and time of last dose Respiratory needs (includes setting) Known allergies

error management Checklists are key tools in reducing mistakes, improving outcomes and reducing cost.

Use of Checklists Aviation- checklist highly regulated and a mandatory part of practice. Aeronautics- best practices were based on several checklist. Product manufacturing- checklist ensures proper operating procedures and maintains standards of quality OR – prevention of wrong: side, site, procedure, person

Research on checklist intervention and its impact on patient safety Safety Attitudes Questionaire (SAQ): Evaluated coordination of care Risk for wrong site surgery Results showed a reduced risk for wrong-site surgery and improved collaboration

Checklists can: Provide guidance Act as a verification after completion of a task Decreased complexity High reliabilty

Checklists objectives: Memory recall Standardization and regulation of processes Provides a framework for evaluations Prevent errors Maintain focus and clarity

Purpose of checklist Defense strategy to prevent errors Memory aid to recall task Facilitate team coordination Create and maintain a safety culture

Checklist method Call-Do-Response Do-Verify Combination of Both Examples: wrong site surgery, unknown med hx, unknown baseline functional and cognitive

Diagram of checklist implementation

Frequency-by-consequence table

conclusion Communication Failures can have severe consequences on patient safety. It takes a team effort to communicate effectively.

References Hales, B.M., Pronovost, P.J. (2006). The checklist- a tool for error management and performance improvement. Journal of Critical Care. 21, 231-235. doi:10.1016/j.jcrc.2006.06.002 Verdaasdonk, E.G.G., Stassen, L.P.S., Widhiasmara, P.P. Dankelman, J. (2009). Requirements for the design and implementation of checklists for surgical processes. Surgical Endoscopy. 23:715-726. Hales, B., Terblanche, M., Fowler, R., Sibbald, W. (2007). Development of medical checklists for improved quality of patient care. 20, 1, 22-30.