1. A Bridge to Safety: A Curriculum for Creating a Safety State of Mind Dr Cindy Gleit Dr Lindsey Konor Dr Steven Livingston Christopher Reed

2. Financial Disclosures No Financial Disclosures

3. Objectives: Identify relevant safety issues in an outpatient setting. Introduce the concept of safety culture to their practice environment. Implement a new model addressing safety in their training programs.

4. Medical Errors Up to 100,000 patients die annually –More than die each year of Alzheimer’s Disease or Diabetes. Errors cost the nation approximately $37.6 Billion annually Medical Errors, 2013. http://www.commonwealthfund.org

7. Outpatient Errors Estimated 1 of 131 outpatient deaths is secondary to a medication error 1 12 million adults are affected by outpatient diagnostic medical errors each year. 2 1. Wittich CM, Burkle CM, Lanier WL. Medication Errors: An Overview for Clinicians. Mayo Clinic Proceedings. 2014; 89(8):1116-1125. 2. Singh H, Meyer AN, Thomas EJ. The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations. BMJ Quality and Safety. 2014;23(9):727-731.

8. How do we address this problem?

9. Addressing the Problem Change the culture of our clinic Introduce a common language of safety Institute reporting and tracking systems

10. Threat and Error Management (TEM)

11. The Basic Model Defenses ThreatsUndesired Outcome

12. The Basic Model Defenses ThreatsUndesired Outcome

13. Threats Threats are anything that make your job more difficult. –Complicating medical conditions –New doctors/nurses –Your physical condition –Your mental condition

14. Defenses Defenses are things you put into place to protect against the incoming threats –Policies and procedures –Communications and huddles –Time management –Electronic Medical Record

15. Provided Defenses Defenses that are out of your direct or immediate control. Things you rely upon without thinking about.

16. Provided Defenses EMR Alerts Policies/Procedures Assisting Personnel Checklists Pharmacists

17. Variable Defenses Defenses that YOU bring to the table. Vary day to day and event to event. Defenses that we can change or improve upon immediately.

18. Variable Defenses Improved Communication Time Management Teamwork “What if” Planning Medical Knowledge

19. Detailed Model PreventTrapMitigate Threats Errors Undesired Consequences Undesired Outcome

20. Errors Any threat that is mishandled becomes an error. Errors are inevitable, because we are human beings.

21. Undesired Consequence An untrapped error becomes an undesired consequence. Filling a syringe with an incorrect drug is a possible undesired consequence.

22. Undesired Outcome If an undesired consequence is not stopped, it can lead to an undesired outcome. –Regulatory infraction –Incorrect medicine administered –Patient infection –Patient death

23. Detailed Model PreventTrapMitigate Threats Errors Undesired Consequences Undesired Outcome

24. Medical Example 1.Threat – –Busy day with multiple patients needing vaccines 2.Error – –Resident orders incorrect vaccine 3.Undesired Consequence – –Nurse selects the incorrect vaccine, and fills the syringe 4.Undesired Outcome – –Nurse administers the incorrect vaccine to the patient

25. Medical Example Multiple “slices” of cheese failed, leading to an undesired consequence. What failed? Think about what examples from your world could apply…

26. Prevent Example Resident realizes that he has multiple patients in for vaccines, and has awareness that this is a threat.

27. Trap Example Resident orders the incorrect vaccine, but the nurse filling the order notices the error when cross-checking the patient’s chart

28. Mitigate Example Nurse fills the syringe with the incorrect vaccine, but cross checks with the patient to confirm that is the vaccine they are expecting to receive.

29. Assessing our Culture and Teaching a Common Language

30. Safety Culture Assessment To be administered to learners before and after didactic sessions and at the end of the academic year. Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, Roberts PR, Thomas EJ. The Safety Attitudes Questionnaire: Psychometric Properties, Benchmarking Data, and Emerging Research. BMC Health Services Research 2006; 6:44.

31. Curriculum Plan Session 1: –Review Concepts –Common Language Session 2: –Errors are inevitable (activity) Longitudinal: –Outpatient Morbidity and Mortality with new model

32. Questions and Comments?

33. Please evaluate this session at: stfm.org/sessionevaluation