1. WRHA Regional Integrated Patient Safety Strategy MCHP Need to Know Session October 17, 2005

2. Regional Integrated Patient Safety Strategy 1.Why? 2.What is RIPSS? 3.Who? 4.When?

3. Patient Safety: Definition The reduction of preventable harm to patients Reduction Preventable Harm (prevention, detection, mitigation) concept of “Getting to Zero”

4. PS 101: The Problem Institute of Medicine (1999) To Err is Human: 44,000-98,000 preventable deaths in hospitalized patients each year in US 90,000 deaths/year from nosocomial infections (CDC, 2002) 218,000 deaths/year from preventable ADE’s (2004) 21 preventable deaths/hour in US (2005, IHI)

5. PS 101: What About Canada? Baker and Norton (2004, CMAJ) Canadian Adverse Event Study 3,700 charts of patients hospitalized in 2000 reviewed 7.5% of patients experienced an adverse event 1.6% of hospitalized patients experienced an adverse event and died 500 bed hospital will have almost 100 preventable adverse events/ month almost 2 deaths/hour

6. PS 101: What about Canada? 2 patient deaths/hour due to healthcare system failure excludes: Psych, obs, paeds, LTC, continuing care, residential and PCH care and all ambulatory care In other words, 2 patient deaths/hour hugely underestimates the impact of patient safety challenges

7. WRHA RIPSS – Why? CCO reporting and management policy: 2002 2004: first full calendar year of data collection Retrospective analysis of acute care CCOs Comparison to Baker/Norton No chart review Assess WRHA’s ability to learn from CCOs and spread to facilities and programs

8. Breakdown of Acute Care CCO’s CCO’s 174 Deaths34 Our current capacity does not support knowing how many were preventable

9. Review Type Overall, 67% of our status reports were “late”, i.e. >40 days

10. Event Review Process: The London Protocol

11. The Results of our Process

12. Results of Review What Works in Patient Safety

13. CCO Recommendations

14. How are we Doing? (Baker/Norton’s Projections for WRHA) AE’s/yr4400 Highly preventable AE’s/yr 1600 Deaths associated with highly preventable AE’s/yr 80 * Numbers based on 100 AE’s/month/500 beds; again, excludes psych, obs. and peds.

15. WRHA Integrated PS Plan Four main components: 1.Promoting culture change 2.Direct involvement of patients and families 3.Learning from clinical practice: RCA retrospective analyses FMEA prospective analyses Trigger tools 4.Promoting change in direct care delivery

16. WRHA: RIPSS Promoting culture change Executive walkrounds Safety surveys (staff) Safety huddles Safety briefings PS simulations Developing a just and fair culture Preventable deaths on the agenda Patient faculty presentations PS week activities Campaign re catching PS butterflies in the safety net “Ever kill someone with your bare hands?” campaign

17. WRHA: RIPSS Direct involvement of patients Formation of provisional PSAC Broadening of Speakup program Creation of town hall series Expansion of PSAC to other sites Safety focus groups and surveys post patient discharge PS resource centres at sites Project specific working groups Patient faculty for health sciences student presentations PS “patient visitors” program

18. WRHA: RIPSS Learning from Clinical Practice CCO/disclosure policy revisions Refine CCO processes – notification, analysis, spread Establish “P&Q” committee P&Q to “close loop” on CCO recommendations Further training of London protocol CCO analysis technique Development of PS SWAT team methodology Identify “preventable deaths” Promote FMEA in sites “Safety net” (NM – good catch) methodology Active surveillance strategies

19. WRHA: RIPSS Promoting change in Care delivery MedRec as regional SHCN! project Support specific SHCN! initiatives Support med safety initiatives Implement and evaluate CCO recommendations Launch falls prevention strategy with targeted pilot Culture change in targeted community hospital research Healthcare CRM initiatives Communication (SBAR) techniques to build teams Development of PS simulation centre

20. WRHA: RIPSS – Who WRHA PS Team now: Robson/Kilpatrick/Sidorchuk/Thomas/Pelletier WRHA PS Team soon: Leader in Human Factors Leader in Applied Learning PS Consultants (CCO Review Specialists) (2) CCO Coordinator (P&Q Committee) WRHA PS Team next year…..

21. WRHA: RIPSS – Who Else? “Ask not what your RHA can do for you, Ask what you can do to advance the cause of patient safety in your region, through your facility” - JFK

22. WRHA: RIPSS – When? Hope is not a plan. Soon is not a time. -Don Berwick (at least 2 patients/hour die in Canada as a result of a healthcare system failure)

23. Comments or questions? Contact Info: Dr. Rob Robson Chief Patient Safety Officer, WRHA 204-926-7075 rrobson@wrha.mb.ca