1. Lessons Learned on Patient Safety
FCC of MHRI

2. The Present Culture
12 minutes for every encounter, 18 seconds elapse before 1st interruption and 75% leave with unanswered questions.
Medication safety: 25% of patients in a year had Adverse Drug Reaction
11% preventable
3% were potential to harm and 95% of these would have been prevented

3. Levels of maturity with respect to a safety culture
E. Risk management is an integral part of everything that we do
D. We are always on the alert for risks that might emerge
The Levels of Safety Culture used in MaPSaF
The best way to understand an safety culture is in terms of an evolutionary ladder. Each level has distinct characteristics and is a progression on the one before. The range runs from the Pathological, through the Reactive to the Calculative and then on to Proactive and the final stage, the Generative.
Pathological, is where the prevailing attitude is ‘why waste our time on safety?’
Reactive, is where safety is taken seriously, but it only gets sufficient attention after things have already gone wrong.
Calculative or bureaucratic organisations are those which have a tick box culture and approach to managing safety. This is where an organization is comfortable with systems and numbers.
Proactive: Proactive organisations consider what might go wrong in the future and take steps before being forced to. Proactive organisations are those where the workforce start to be involved in practice, not just in theory.
Generative organizations are the nirvana of a mature safety culture. They live in a state of ‘chronic unease’ and are mindful of what could go wrong, trying to be as informed as possible, because it prepares them for whatever will be thrown at them next. At this level bad news is actively looked for, because it provides the best opportunity to learn, so messengers are trained and welcomed.
NB THIS SLIDE REPEATS SOME OF THE INFORMATION ON PRECEDING SLIDES TO FAMILIARISE THE AUDIENCE WITH KEY TERMS
C. We have systems in place to manage all identified risks
B. We do something when we have an incident
A. Why waste our time on safety?
PATHOLOGICAL
REACTIVE
BUREAUCRATIC
PROACTIVE
GENERATIVE

4. Safety Minefields Transitions of Care Missed or Delayed Diagnoses
20% after discharge had a significant result: Med errors lead the pack
Only 25% mentioned pending tests F/U
Missed or Delayed Diagnoses
Cognitive Errors: Reliance on Memory
Test tracking, Ordering of tests and F/U
Referrals: timeliness and clarity

5. Medication Pitfalls
Survey says: 200,000 Rxs written only 72% were filled
Adherence and Medication reconciliation
Ask-Educate-Ask

6. Take home Points Transitions of Care
Template for first visit after discharge
Bullet points on Discharge summary of most important topics, pending tests, labs and procedures done
Must be available at first visit: only 12% are available
Medication Reconcilliation at every step

7. Test Tracking No News is not good news!
How does the patient prefer to be contacted about results: phone, , snail mail
If you do not hear from the office in X amount of time after the study should take the initiative to contact the office.
Order entry will help not to lose tests
Tickler systems essential for tests and referrals
Standardize process and procedures

8. Culture of Safety Walk Rounds
Senior level engaging and NON-punitive
Safety Huddles: Huddles to Shape the Day and regular huddles
Debriefings at the End of the Day and after any event.
Event Reports: Primary Care M & M

9. Culture of Safety Need safe and supportive Accountability
Need Resources
Clinical Decision Support at P.O.C.: Algorithms
Big hitters: Cancer prevention,tests and follow up
Communication in the office, at the hospital, with the specialists and the administration
Consistency, Teamwork, Safe environment

10. Tools Trigger Tools Ambulatory Safety Survey: ARQHC
MGMA: Patient Safety Score
Donabedian: Structure + Process = Outcome
MaPSaF safety culture assessment

11. Trigger Tool

12. Primary Care Trigger Tool

13. London Protocol

14. Tool Benefits

15. Individual Benefits

16. Framework Document
This is the tool itself – it starts A4 size and folds out to a large table-top size – ideal for group work and for encouraging discussion.
The tool comes with full supporting explanatory notes and explains some of the background to its development.

17. Next steps Pre Huddles and post Huddles Trigger Tool Use
Better tracking of tests, reports, reminders
Transparent Walk Rounds
Standardization for test notification,
Standardization for using EMR medication reconcilliation
Keep up the transition of care excellence
Decision support tools in the EMR
First visit post hospitalization template
Patient surveys and practice survey tools