Safety: It’s Everybody’s Business Virginia Ingram, MSN, RN Patient Safety Officer University of Mississippi Medical Center

Too fast….too far down the runway!

“Most errors are made by good but fallible people, working in a challenged and imperfect system.”

Error is Inevitable Because of Human Limitations * Limited memory capacity – 5-7 pieces of information in short term memory * Negative effects of stress – ↑ error rates * Negative influence of fatigue and other physiological factors * Limited ability to multitask – cell phones and driving

Human Error is Also Inevitable Because: * Safety is often assumed, not assured * Culture of the expert individual – mistakes not allowed * AND…….

Complex, unsafe systems

THEN WE HAVE HUMAN JUDGMENT

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What can we learn from the Airline Industry? Before intervention, 70% of air crashes involved human error rather than failures of equipment or weather

Crew Resource Management * Focus on teamwork, communication, flattening hierarchy, managing error, situational awareness, decision making * Non-punitive reporting of near misses * Very open culture with regard to error and safety

PATIENT SAFETY Without Safety, there is no Quality.

What is Patient Safety? In its simplest form, patient safety is prevention of harm to patients. We are all in the business of Patient Safety!!!!

The Legal Fallacy of the Low Risk Patient There are NO LOW RISK patients! Most medical legal claims come from low risk patients with poor outcomes ! There are NO LOW RISK patients! Most medical legal claims come from low risk patients with poor outcomes !

IT STARTED WITH THE IOM REPORT NOVEMBER 1999 KEY FINDINGS:  PREVENTABLE MEDICAL ERRORS CAUSE 44,000-98,000 DEATHS/YEAR IN U.S.  ERRORS OCCUR BECAUSE OF SYSTEM FAILURES  PREVENTING ERRORS MEANS DESIGNING SAFER SYSTEMS OF CARE

JCAHO Patient Safety Goals Patient Identification Patient Identification Communication among caregivers Communication among caregivers Medication Safety Medication Safety Infusion Pumps Infusion Pumps Healthcare Acquired Infection Prevention Healthcare Acquired Infection Prevention Medication Reconciliation Medication Reconciliation Falls Prevention Falls Prevention Universal Protocol Universal Protocol Labeling of Medications Labeling of Medications Clinical Alarms Clinical Alarms

Sentinel Events Suicide of any individual receiving care or within 72 hours of discharge Suicide of any individual receiving care or within 72 hours of discharge Abduction of any individual receiving care, treatment or services Abduction of any individual receiving care, treatment or services Wrong Site, Wrong Patient Surgery Wrong Site, Wrong Patient Surgery Incompatible blood transfusion, hemolytic reaction incompatible blood Incompatible blood transfusion, hemolytic reaction incompatible blood Death from hospital infection or major permanent loss of function associated with health-care acquired infections Death from hospital infection or major permanent loss of function associated with health-care acquired infections Rape Rape Retained foreign object unintended retention of a in an individual after surgery or other procedure Retained foreign object unintended retention of a in an individual after surgery or other procedure Adverse Patient Occurrences warranting expanded investigation Adverse Patient Occurrences warranting expanded investigation

What Must We Do?  Create Culture of Safety Safety is at the center of all efforts!

Safety is Everybody’s Business Commitment and participation of ALL employees and staff Commitment and participation of ALL employees and staff Leadership Safety Walkarounds Leadership Safety Walkarounds

What Else Should We Do? Encourage error reporting in a Non-punitive system Encourage error reporting in a Non-punitive system  Help staff understand risk, accept responsibility for harm, lead efforts to prevent harm  Recognize errors as opportunities for reducing risk  Teach staff how error reports help to track/trend safety issues and improvement of processes  Don’t tolerate cover-ups  Support employees involved in serious errors  Perform Root Cause Analyses whenever indicated

Why Is This Hard ? Trained to be perfect — knowledge and competence are equated with the absence of error Trained to be perfect — knowledge and competence are equated with the absence of error Medical culture rewards perfection and frowns upon error Medical culture rewards perfection and frowns upon error Individual agency — fix the person and the problem goes away Individual agency — fix the person and the problem goes away

Don’t Forget to Improve Communication and Team Work Focus on common goal of safe patient care Focus on common goal of safe patient care Promote teamwork training Promote teamwork training Standardize Communication (SBAR) Standardize Communication (SBAR) Apply Crew Resource Management techniques Apply Crew Resource Management techniques  Use 3 rd person when communicating “WE” Develop checklists Develop checklists  Hand-offs, procedures Initiate teamwork training in professional schools, residency programs Initiate teamwork training in professional schools, residency programs

Of Course, Include Patients and Families in Patient Safety Empower patients and families to actively participate in care Empower patients and families to actively participate in care Include patients and families on safety teams, in safety walk arounds Include patients and families on safety teams, in safety walk arounds Establish patient advocacy groups to advise leaders Establish patient advocacy groups to advise leaders

Of Course, Include Patients and Families in Patient Safety Empower patients and families to actively participate in care Empower patients and families to actively participate in care Include patients and families on safety teams, in safety walk arounds Include patients and families on safety teams, in safety walk arounds Establish patient advocacy groups to advise leaders Establish patient advocacy groups to advise leaders

Measure Results and Monitor Progress CMS Quality Metrics CMS Quality Metrics AHRQ Patient Safety Indicators AHRQ Patient Safety Indicators JCAHO National Patient Safety Goals JCAHO National Patient Safety Goals IHI 100,000 Lives Campaign IHI 100,000 Lives Campaign NQF safe practices NQF safe practices National Patient Safety Foundation National Patient Safety Foundation Leapfrog initiatives Leapfrog initiatives FMECA FMECA Internal and External Benchmarks Internal and External Benchmarks

What Hinders a Patient Safety Program? Hierarchy / power distance Hierarchy / power distance Failure to communicate Failure to communicate Lack of common mental model Lack of common mental model Not having a voice Not having a voice Lack of respect Lack of respect Fear of retribution Fear of retribution

It may be part of human nature to err, but it is also a part of human nature to create solutions, find better alternatives, and meet the challenges ahead

Up, Up, and Away with Patient Safety