1. Revisiting Learning From Defects: An Intervention to Learn from Mistakes David A. Thompson DNSc, MS, RN Associate Professor Armstrong Institute for Patient Safety and Quality Johns Hopkins University School of Medicine

2. Culture is Important Respecting the wisdom of frontline workers Assessing the context of care: provider teamwork (collaboration), perceptions of management, patient safety norms hierarchy 2

3. Culture is Important Joint Commission data show that Communication breakdowns are the leading root cause of: Sentinel Events Medication Errors Perinatal Deaths & Injuries Delays in Treatment Wrong Site Surgeries Ventilator events 3

4. Culture is Measurable Culture is local Data collected and interpreted at unit level Representativeness -vs- Representative Mess –Partial sampling is not adequate for year to year comparisons High Response Rates are easy to interpret & difficult to ignore 4

5. % of respondents reporting above adequate teamwork 5

6. Teamwork Disconnect RN: Good teamwork means I am asked for my input MD: Good teamwork means the nurse does what I say 6

7. % of respondents within an ICU reporting good teamwork climate Teamwork Climate Across Michigan ICUs No BSI 21% No BSI 21% No BSI 44% No BSI 44% No BSI 31% No BSI 31% No BSI = 5 months or more w/ zero The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care 7

8. Steps of CUSP 1.Educate staff on Science of Safety 2.Identify defects 3.Assign executive to adopt unit 4.Learn from one defect per quarter 5.Implement teamwork tools Pronovost J, Patient Safety, 2005 8

9. Lesson Learned: Errors are the result of system failures “Every System is Perfectly Designed to Achieve the Results it Does” Batalden Berwick http://www.mederrors.org/1998/html/keynote.html 9

10. System Factors Impact Safety Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Institutional 10

11. The Work of Adaptive Change Determining the direction – what must change Determining the methods – how to change 11

12. Step 4: Learning from Mistakes aka Learning from defects What happened? Why did it happen (system lenses) ? What could you do to reduce risk ? How do you know risk was reduced ? –Create policy / process / procedure –Ensure staff know policy –Evaluate if policy is used correctly Pronovost 2005 JCJQI 12

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14. What is a Defect? Anything you do not want to have happen again 14

15. Assessing Defects Staff Safety assessment –Please describe how you think the next patient in your unit/clinical area will be harmed. Adverse event reporting systems Sentinel events Complications Infection rates Mortality and morbidity conference Claims data 15

16. 4 Questions to Learn from Defects What happened? Why did it happen? What will you do to reduce the chance it will recur? How do you know that you reduced the risk that it will happen again? 16

17. What Happened? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking and the reasoning behind their actions/decisions Try to view the world as they did when the event occurred Reason J. Human Error. Cambridge, UK: Cambridge Univ Pr; 1990. 17

18. What Happened? Talk about and understand what happened Complete the “What Happened?” section of the Learning from Defects tool. 10 minutes 18

19. Why did it Happen? Review the list of factors that contributed to the incident and check off those that negatively contributed and positively contributed to the defect Negative contributing factors are those that harmed or increased risk of harm for the patient Positive contributing factors limited the impact of harm 19

20. Why did it Happen? Develop lenses to see the system (latent) factors that lead to the event Often result from production pressures Damaging consequences may not be evident until a “triggering event” occurs Reason J. Human Error. Cambridge, UK: Cambridge Univ Pr; 1990. 20

21. Why did it Happen? Complete the contributing factors section Items may positively contribute, negatively contribute, or not apply (n/a) These are examples but you may identify factors that are not listed, if so, write down 21

22. Why did it Happen? Review the list of contributing factors and identify the most important factors related to this event. Rate each contributing factor on its importance to this event and future events. 22

23. What will you do to reduce the risk? Safe design principles –Standardize what we do Eliminate defects –Create independent checks –Make it visible Safe design applies to technical and team work 23

24. What will you do to reduce the risk? Review the 2-5 most important contributing factors Brainstorm Interventions –Develop an intervention to defend against the 2-5 most important contributing factors –Identify the strongest interventions that are feasible. –Identify a metric that you can use to measure the impact of the intervention Rate each intervention for its ability to mitigate the contributing factor and the teams belief that the intervention will be implemented and executed 24

25. What will you do to reduce the risk? Select top interventions (2 to 5) and develop intervention plan Assign person and task follow-up date 25

26. Strength of Interventions Weaker ActionsIntermediate ActionsStronger Actions Double CheckChecklists/ Cognitive AidArchitectural/physical plant changes Warnings and labelsIncreased Staffing/Reduce workload Tangible involvement and action by leadership in support of patient safety New policy, procedure, or memorandum RedundancySimplify the process/remove unnecessary steps Training and/or education Enhance Communication (read-back, SBAR etc.) Standardize equipment and/ or process of care map Additional Study/analysis Software enhancement/modifications New device usability testing before purchasing Eliminate look alike and sound- a-likes Engineering Control of interlock (forcing functions) Eliminate/reduce distractions Adapted from John Gosbee, MD, MS Human Factors Engineering Remember sometimes a weaker action is your only option. 26

27. Near Miss 27

28. A Medication Error Story 63 year old man with sternal infection transferred to the ICU Allergy to Penicillin noted in chart Treatment includes Piperacillan 25 minutes after dose, patient arrests Antibiotic reaction regarded as likely trigger 28

29. A Medication Error Story Nurse borrows medication from another patient Fax system for ordering medications is broken Tube system for obtaining medications is broken Nurse gives the patient a medication to which he is allergic ICU nurse staffing Patient arrests and dies 29

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32. Impact of ICU Nurse Staffing on Outcomes* Fewer ICU nurses associated with increased LOS risk of pulmonary complications Pulmonary insufficiency Reintubation of trachea Pneumonia *Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract. 2001;4:199- 206. 32

33. Impact of Pharmacist on Outcomes* Pharmacist participation on daily rounds in the ICU associated with 66% reduction in adverse drug events (ADEs) ADEs reduced 10.4/1000 pt days to 3.5 Prevent one ADE every 143 patients Leape *Leape LL, Cullen DJ, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA.1999;282(3):267-270. 33

34. Problem Solving* First Order –Recovers for that patient yet does not reduce risks for future patients –Example: You go get the supply or you make do Second Order –Reduces risks for future patients by improving work processes –Example: You create a process to make sure line cart is stocked *Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. California Management Review, 2003 ;45(2):55-72. 34

35. Improve Pain Management 1.Educate Staff 2.Put VAS card at bedside 3.Have residents report pain scores 4.Define defect as pain score > 3. Erdek Pronovost 35

36. PDSA1 PDSA2PDSA3PDSA4 36

37. Improve Pain Management 37

38. How do you know risks were reduced? Did you create a policy or procedure (weak)? Do staff know about policy or procedure? Are staff using the procedure as intended? –Behavior observations, audits Do staff believe risks were reduced? 38

39. How do you know risks were reduced? Once interventions have been implemented complete the “Describe Defect” and “Interventions” portion of section IV of the Learning from Defect Tool. Distribute to staff to rate: –The effectiveness of the implementation –How effective the intervention has been at reducing reoccurrence of the defect 39

40. Summarize and Share Findings Summarize findings (Case Summary ) Share within your organizations Share de-identified findings with others in collaborative (pending institutional approval) 40

41. Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity. Regular training and education, even if infrequently used, of all devices and equipment. Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together. Label wires and sheaths noting the appropriate partner for this device. ACTIONS TAKEN TO PREVENT HARM IN THIS CASE The bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together. Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath. Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire. CASE IN POINT: An African American male ≥ 65 years of age was admitted to a cardiac surgical ICU in the early morning hours. The patient was status-post cardiac surgery and on dialysis at the time of the incident. Within 2 hours of admission to the ICU it was clear that the patient needed a transvenous pacing wire. The wire was Threaded using an IJ Cordis sheath, which is a stocked item in the ICU and standard for PA caths, but not the right size for a transvenous pacing wire. The sheath that matched the pacing wire was not stocked in this ICU since transvenous pacing wires are used infrequently. The wire was threaded and placed in the ventricle and staff soon realized that the sheath did not properly seal over the wire, thus introducing risk of an air embolus. Since the wire was pacing the patient at 100%, there was no possibility for removal at that time. To reduce the patient’s risk of embolus, the bedside nurse and resident sealed the sheath using gauze and tape. Safety Tips:  Label devices that work together to complete a procedure  Rule: stock together devices need to complete a task SYSTEM FAILURES: OPPORTUNITIES for IMPROVEMENT: 41

42. Fellow DefectInterventions 1Unstable oxygen tanks on bedsOxygen tank holders repaired or new holders installed institution-wide 2Nasoduodenal tube (NDT) placed in lungProtocol developed for NDT placement 3Medication look-alikeEducation, physical separation of medications, letter to manufacturer 4Bronchoscopy cart missing equipmentChecklist developed for stocking cart 5Communication with surgical services about night coverage White-board installed to enhance communication 6Inconsistent use of Daily Goals rounding toolGained consensus on required elements of Daily Goals rounding tool 7Variation in palliative care/withdrawal of therapy orders Orderset developed for palliative care/withdrawal of therapy 8Inaccurate information by residents during roundsDeveloping electronic progress note 9No appropriate diet for pancreatectomy patientsDeveloping appropriate standardized diet option 10Wrong-sided thoracentesis performedEducation, revised consent procedures, collaboration with institutional root-cause analysis committee 11Inadvertent loss of enteral feeding tubePilot testing a ‘bridle’ device to secure tube 12Inconsistent delivery of physical therapy (PT)Gaining consensus on indications, contraindications and definitions, developing an interdisciplinary nursing and PT protocol 13Inconsistent bronchoscopy specimen laboratory ordering Education, developing an order set for specimen laboratory testing Critical Care Fellowship Program* *Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual. 2009;24(3):192-5. 42

43. Key Lessons Focus on systems… not people Prioritize Use safe design principles Go mile deep and inch wide rather than mile wide and inch deep Pilot test Answer the 4 questions 43

44. Action Plan Complete staff safety assessment (repeat) Review the Learning from Defect tool with your team Select one defect per month/quarter to learn from Post the stories of risks that were reduced Share with others, in fact…. 44

45. References Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75. Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68. Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479. 45