Title: The Science of Safety Armstrong Institute for Patient Safety and Quality Presented by: David A. Thompson, DNSc, MS, RN Title: Associate Professor

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

RAND Study Confirms Continued Quality Gap Condition % of Recommended Care Received Low back pain 68.5 Coronary artery disease 68.0 Hypertension 64.7 Depression 57.7 Orthopedic conditions 57.2 Colorectal cancer 53.9 Asthma 53.5 Benign prostatic hyperplasia 53.0 Hyperlipidemia 48.6 Diabetes mellitus 45.4 Headaches 45.2 Urinary tract infection 40.7 Hip fracture 22.8 Alcohol dependence 10.5 1. McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.

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.

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

Understanding the Science of Safety

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

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

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.

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.

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

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

Standardize

Line Cart Contents – 4 Drawers

Eliminate Steps

Create Independent Checks

Principles of Safe Design Apply to Technical and Team Work

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.

Train & Coach Adaptive Team Behaviors Leadership Delegation Resource management Modeling good teamwork skills Communication Closed-loop communication Using clear, structured communication Mutual Support Task assistance Conflict resolution Feedback Situation Monitoring Shared mental models Cross-monitoring TeamSTEPPS® Competency Framework Teamstepps.ahrq.gov

Team Training: Does it work? Team training is a strategy for systematically improving teamwork competencies: the knowledge, skill, and attitudes (KSAs) underlying effective teamwork. Team training significantly improves team1: Cognition (ρ = .42) Shared mental models Behavioral process (ρ = .44) Communication, coordination, collaboration Affect (ρ = .35) Mutual trust, collective efficacy Performance outcomes (ρ = .37) Task outcomes, satisfaction, viability 1Salas et al., 2008

But, Does it Work in Healthcare? Learner reactions are positive 1,2 Learning occurs 1,2 Behavior change in transfer environment occurs.1,2 Improved efficiency in clinical processes3-6 Improved clinical outcomes7,8 1Rabøl et al., 2010 2Weaver et al., 2010 3Sissakos et al., 2009 4Wolf et al., 2010 5Capella et al., 2010 6Deering et al., 2011 7Mann et al., 2006 8Neily et al., 2010

TeamSTEPPS® Communication is… The process by which information is exchanged between individuals, departments, or organizations The lifeline of the Core Team Effective when it permeates every aspect of an organization Assumptions Fatigue Distractions HIPAA

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

Comprehensive Unit based Safety Program (CUSP) CUSP & Teamwork Comprehensive Unit based Safety Program (CUSP) Educate staff on science of safety Identify defects Assign executive to adopt unit Learn from one defect per quarter Implement teamwork tools Teamwork tools: Call list Daily goals AM briefing Shadowing Observing rounds Learning from defects* TeamSTEPPS® 9/9/2019 Armstrong Institute for Patient Safety and Quality

TeamSTEPPS® Standards of Effective Communication Complete Communicate all relevant information Clear Convey information that is plainly understood Brief Communicate the information in a concise manner Timely Offer and request information in an appropriate timeframe Verify authenticity Validate or acknowledge information

TeamSTEPPS® Communication Challenges Language barrier Distractions Physical proximity Personalities Workload Varying communication styles Conflict Lack of information verification Shift change Great Opportunity for Quality and Safety

TeamSTEPPS® Teamwork Actions Communicate with team members in a brief, clear, and timely format Seek information from all available sources Verify and share information Practice communication tools and strategies daily (SBAR, call-out, check-back, handoff)

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.

Recap Develop lenses to see systems Work to standardize one process Infuse these principles of standardization and independent checks in other processes

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.

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.

Armstrong Institute for Patient Safety and Quality dthomps1@jhmi.edu Armstrong Institute for Patient Safety and Quality