1. Patient Safety in the AMEDD
LTC Steven W. Grimes
AMEDD Patient Safety Program Manager
USA MEDCOM

2. Make the Safest Way the Best Way!
Objectives
Briefly Review Key Patient Safety Concepts and Program Definitions
Discuss Components of the AMEDD Patient Safety (PS) Program
Provide Overview of Joint Commission (JC) Patient Safety Standards and 2004 National Patient Safety Goals
Make the Safest Way the Best Way!

3. Make the Safest Way the Best Way!
Definition
Patient Safety
Actions undertaken by individuals and organizations to protect health care recipients from being harmed by the effects of health care services.
Safety in health care is not a new concept. Programs have been in place for many years that are designed to provide a safe and healthy environment where hazards are eliminated or minimized for employees, staff, patients, and visitors. What has been missing from these programs is the “human” component of patient care. Health care is a complex system and people who work in this system make mistakes. A comprehensive Patient Safety Program is designed to look for ways to help caregivers focus on ways to minimize the potential for patient harm.
Make the Safest Way the Best Way!

4. Why the Focus on Patient Safety?
Right Thing to Do!
Saves lives, saves money
Response to the “Deadly Secret”
IOM Report - To Err is Human
44,000-98,000 deaths due to medical error
National Cost: $17-29 Billion/year
10-35% suffer from preventable adverse drug events cost hospitals $2 Billion/year
Federal Mandate & Regulatory Requirement
Presidential Directive, NDAA, DoDI, DoD IG
JCAHO requirements
Medical error 5th leading cause of death in US (CVS, CA, Stroke, COPD)
IOM estimated 50% of adverse medical events due to “preventable” errors
National Costs (lost income, disability, and HC costs) up to 29B/year
Increase in HCO cost by $4,700/adm ($2.8 mil/yr for 700 bed facility)
HCFA Rule change will require all Medicare participating hospitals to implement medical error reduction programs (SAFE Bill – Stop all frequent errors in Medicare and Medicaid Act of 2000)
1. Establish medical safety programs that produce measurable reduction in errors
2. Identify root causes of errors and take steps to prevent future errors
3. Disclose to the public name and address of facilities that fail to comply with reporting requirements
4. Establish Center for Patient Safety to study topic
5. BBA roll backs for clinical information systems that reduce errors
Make the Safest Way the Best Way!

5. Make the Safest Way the Best Way!
Deadly Secret
100000
Fire
80000
Drowning
60000
Poisoning
40000
Falls
How an estimated 98,000 deaths each year from hospital error compare with the top five leading causes of accidental death n the US.
It doesn’t matter if you use the 44,000 or 98,000 figure or even 120,-150,000 the the deaths resulting in medical error still exceed the other 5 leading causes of accidental death.
This is equivalent to one jumbo jet crashing every day.
Your chances of dying in an aircraft accident are 1 in 300,000 and your chances of dying in an acute care facility (as a result of a medical error) is 1 in 200.
MVA
20000
Med Errors
OOPS!!
3700
4100
8400
16,600
41,200
98,000
Make the Safest Way the Best Way!

6. Make the Safest Way the Best Way!
Program Goals
Reduce chance of human error reaching & harming patients
Promote culture to facilitate reporting
Focus on system/process design NOT individual involved
Ask What happened & Why NOT Who…
‘Paradigm Shift’ from current practice!
Make the Safest Way the Best Way!

7. “Latent” Failures in the
The “Swiss Cheese” Model of Accident Causation (Reason, 1990)
Excessive cost cutting
Drive to Reduce Hospital Days
Organizational
Factors
Unsafe
Supervision
Deficient training program
Inexperienced X-Ray Tech
Preconditions
for
Unsafe Acts
Colleague Admitted Patient
Poor Coordination
Unsafe
Acts
Wrong X-ray marker used
Prepped Wrong Leg
“Latent” Failures in the
System
Complex systems fail because of the combination of multiple small failures, each individually insufficient to cause an accident. These failures are latent in the system and their pattern changes over time.
Bottom line is that the system has holes in it. Goal is to keep them from lining up and leading to major incident.
Wrong Site Surgery
ACCIDENT & INJURY

8. Make the Safest Way the Best Way!
Current Reality
Error prevention is often hampered by:
Lack of clear lines of authority, accountability and responsibility
Fragmented approaches spread out over multiple bodies, committees, departments and individuals
Incidence of errors are severely under-reported due to:
Fear of reprisal
Ineffective and limited reporting mechanisms
Insufficient aggregate data to analyze and make decisions
Make the Safest Way the Best Way!

9. Make the Safest Way the Best Way!
Culture & Reporting
Cultural Change Needed
Encourage institutional learning from errors
Focus on systems and processes
Minimize individual blame
Promote voluntary reporting of errors
Part of the AMEDD Patient Safety Program involves changing the current reporting culture to one that 1) encourages institutional learning from errors, 2) focuses on systems and processes, and 3) minimizes individual blame so staff members, like yourselves, voluntarily take an active role in error reduction by reporting actual and potential health care errors.
Make the Safest Way the Best Way!

10. Make the Safest Way the Best Way!
Safe System Design
Organizational Change
Increase feedback
Teamwork
Drive out fear
Leadership commitment
Improve direct communication
Process Design
Reduce reliance on memory and vigilance
Simplify
Decrease Variation
Checklists
Forcing functions
Eliminate look &
sound a-likes
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11. Patient Safety &
The Joint Commission

12. Patient Safety Program Survey Expectations
MTF-wide PS Program Implementation
1 year ‘track record’ - 1 July 02
“Annual” Requirements:
Select high-risk process
Complete 1st Annual FMEA – 1 July Sep 02
Complete 2nd Annual FMEA – 1 Jul 02 – 1 Jul 03
Start on number Jul 03 – 1 Jul 04
Implement PS Goals - 1 Jan 03
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13. Survey Process Overview
Patient safety primary focus
Leadership interviews to evaluate if Patient Safety is an organizational priority
Onsite survey agenda reflecting emphasis on Patient Safety
Pt unit visits and staff interviews evaluate actual practice and performance
Tracer Methodology
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14. Patient Safety &
Health Literacy

15. Make the Safest Way the Best Way!
Health Literacy
What is Health Literacy?
Do we have a problem with Health Literacy?
What can you do to help?
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16. Patient Safety &
MEDCOM

17. Make the Safest Way the Best Way!
AMEDD Leading the Way!
MEDCOM Regulation 40-41: The Patient Safety Program
Establishes “Standardized” Corporate Program (Currently under revision)
Supports all Regulatory Requirements
Specific implementation guidance for
DoD Instruction
NDAA 2001
JCAHO PS Standards
As on of it’s initiatives, the DoD WG created “Department of Defense Instruction/Service Implementation Guidelines” sometimes referred to as the “DoDI” (pronounced “DOE-dee”).
The DoDI establishes a Patient Safety Program whose system is modeled after Dept of VA Program. It is focused on prevention, not punishment and on improving medical systems. It establishes a Patient Safety Registry through AFIP. All services report patient safety event data to AFIP for the purpose of looking at event data, DoD-wide trends, and best/safe practices and reporting back to the field. The program complies with confidentiality statutes.
Make the Safest Way the Best Way!

18. Make the Safest Way the Best Way!
Definitions of Terms
Patient Safety (PS) Event
Incident that occurred (actual event) or almost occurred (close call/near miss) that caused or had the potential to cause harm to a patient
3 Types of PS Events
Close Call/Near Miss
Adverse Event
Sentinel Event
Make the Safest Way the Best Way!

19. Make the Safest Way the Best Way!
Near Miss*
Any process variation or error that could have resulted in harm to a patient, visitor or staff, but through chance or timely intervention did not reach the individual. Such events have also been referred to as ‘close call(s)’
*Per DoD PS Planning & Coordination Committee (PSPCC) as of Jan 03
Make the Safest Way the Best Way!

20. Make the Safest Way the Best Way!
Adverse Event
Occurrence associate w/ provision of health care or services that may or may not result in patient harm
Acts of commission or omission
**Patient falls or improper medication administration, even if NO patient harm, fall into this PS event category
Make the Safest Way the Best Way!

21. Make the Safest Way the Best Way!
Sentinel Event
Unexpected occurrence involving death, serious physical or psychological injury, “or risk thereof”
Make the Safest Way the Best Way!

22. JC Reviewable Sentinel Events
Applies to recipients of care
Applies only to events that meet the following criteria:
Event resulted in unanticipated death or major permanent loss of function
Not related to the natural course of illness OR
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23. JC Reviewable Sentinel Events
Suicide in a 24-hour Care Setting
Infant Abduction/DC Wrong family
Rape (by another pt, visitor, staff)
Hemolytic Transfusion Reaction
Surgery Wrong Patient/Body Part
Unanticipated death of a full term infant
Make the Safest Way the Best Way!

24. Other JC “Reviewable” Sentinel Events
Medication Error resulting in Death, Paralysis, Coma or other Permanent Loss of Function
Maternal Death (Intrapartum/Related to Birth Process)
Fall resulting in Death or Permanent Loss of Function (Direct Result of Sustained Injuries)
Fatal Nosocomial Infection considered SE and is reviewable
Surgical Fires SE Alert #29
- Any pt death, paralysis, coma or other permanent loss of function associated w/ med error.
Any elopement, resulting in temporally related death (suicide/homicide), or major permanent loss of function.
Any intrapartum (related to the birth process) maternal death.
Death of full term infant w/ wgt 2500gms
Pt fall results in death
Make the Safest Way the Best Way!

25. JC SE Statistics (From Jan 95 – Dec 04) current as of 22 February 2005
2966 Sentinel Events Reviewed by JC
Categories of SE’s to date include:
415 Patient Suicide Patient Elopement
370 Wrong-Site Surgery 57 Infection –Related Event
365 Op/post-op Complication Fire
326 Medication Error 49 Anesthesia-related Event
221 Delay in Treatment 39 Ventilator Death/Injury
144 Patient Fall Maternal Death
124 Restraint Death/Injury Med Equip Deaths
107 Assault/Rape/Homicide Infant Abduction/wrong families
85 Transfusion Error 18 Utility Systems-related Event
84 Perinatal Death/Loss Function Other less frequent types
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26. Identified Root Cause/ Contributing Factors
DoD
1. Communication*
2. No Policy/Procedure
3. Policy/Procedure not Followed
4. Inadequate Documentation
5. Lack of Training*
6. Staffing Levels*
7. Lack of Experience
8. Equipment Malfunction/
Availability
JCAHO
1. Communication*
2. Orientation/Training*
3. Patient Assessment
4. Availability of Information
5. Staffing Levels*
6. Physical Environment
7. Competency/Credentialing
8. Procedural Complications
9. Alarm Systems
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27. Make the Safest Way the Best Way!
Communication
We know that communication is a problem, but we’re not going to discuss it with the troops!
Make the Safest Way the Best Way!

28. Systems Evaluation (JC Minimum Scope of RCA)
Equipment Maintenance/ Management
Technological Support
Communication
Between Staff
Patient/Family
Control of Medications
Storage/Access
Labeling
Security Systems/Processes
Patient Assessment
Patient Identification
Care Planning Process
Availability of Information
Orientation & Training
Competence Assessment/ Credentialing
Staff Supervision
Staffing Levels
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29. Root Cause Analysis (RCA)
A process for identifying the basic and causal factors that underlie variation in performance, to include the occurrence or possible occurrence of a sentinel event
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30. JCAHO National Patient Safety Goals for 2005

31. JC National Patient Safety Goals
Originally Published 24 July 02
Effective 1 Jan 05
MTFs must be in compliance
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32. 2005 Hospitals' National Patient Safety Goals
Goal: Improve the accuracy of patient identification.
Use at least two patient identifiers (neither to be the patient's room number) whenever administering medications or blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures.
Make the Safest Way the Best Way!

33. 2005 Hospitals' National Patient Safety Goals
Goal: Improve the effectiveness of communication among caregivers.
For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the order or test result "read-back" the complete order or test result.
Standardize a list of abbreviations, acronyms and symbols that are not to be used throughout the organization.
Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values.
Make the Safest Way the Best Way!

34. 2005 Hospitals' National Patient Safety Goals
Goal: Improve the safety of using medications.
Remove concentrated electrolytes (including, but not limited to, potassium chloride, potassium phosphate, sodium chloride >0.9%) from patient care units.
Standardize and limit the number of drug concentrations available in the organization.
Identify and, at a minimum, annually review a list of look-alike/sound-alike drugs used in the organization, and take action to prevent errors involving the interchange of these drugs.
Make the Safest Way the Best Way!

35. 2005 Hospitals' National Patient Safety Goals
Goal: Improve the safety of using infusion pumps.
Ensure free-flow protection on all general-use and PCA (patient controlled analgesia) intravenous infusion pumps used in the organization.
Make the Safest Way the Best Way!

36. 2005 Hospitals' National Patient Safety Goals
Goal: Reduce the risk of health care-associated infections.
Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.
Make the Safest Way the Best Way!

37. 2005 Hospitals' National Patient Safety Goals
Goal: Accurately and completely reconcile medications across the continuum of care.
During 2005, for full implementation by January 2006, develop a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.
A complete list of the patient's medications is communicated to the next provider of service when it refers or transfers a patient to another setting, service, practitioner or level of care within or outside the organization.
Make the Safest Way the Best Way!

38. 2005 Hospitals' National Patient Safety Goals
Goal: Reduce the risk of patient harm resulting from falls (hospital).
Assess and periodically reassess each patient's risk for falling, including the potential risk associated with the patient's medication regimen, and take action to address any identified risks.
Make the Safest Way the Best Way!

39. 2005 Hospitals' National Patient Safety Goals
Goal: Reduce the risk of surgical fires (ambulatory).
Educate staff, including operating licensed independent practitioners and anesthesia providers, on how to control heat sources and manage fuels, and establish guidelines to minimize oxygen concentration under drapes.
Make the Safest Way the Best Way!

40. NPSG Evaluation & Scoring
Apply to ALL accreditation programs
Includes All Full Surveys & Unannounced Surveys
Must implement all goals/recs relevant to scope of services, or implement JC approved alternative
Surveyors evaluate actual performance, not just intent
Are recommendations implemented & how consistently are they being done
Expected track record from 1 Jan 03 to survey date
Failure to address 1 or more recommendation, will result in a Recommendation for Improvement or a Supplemental Recommendation for Improvement.
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41. Make the Safest Way the Best Way!
How Can You Assist?
Become educated on AMEDD PS Program & roles/responsibilities in daily practice
Report all close calls, adverse events & sentinel events
Ensure patient/family educated on how they can participate to facilitate safe care
Remain informed of safety alerts & implement identified safe/best practices
Integrate JC PS Goals into daily practice
Make the Safest Way the Best Way!

42. AMEDD - Leading the Way! Our Key to Success is MTF Program ‘Execution’
We need each of YOU to
share your knowledge/expertise & become active participants in clinical safety to
transition to an environment of
Cooperation
STANDARDIZED????
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43. Make the Safest Way the Best Way! Make the Safest Way the Best Way!
Conclusion
Working together to
Make the Safest Way the Best Way!
Thank You!
Make the Safest Way the Best Way!

44. Make the Safest Way the Best Way!
Remember
This project is so important, we can’t let things that are more important interfere with it.
Make the Safest Way the Best Way!