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2. UCH Patient Safety Tools For the Front Line An Analysis of Human Factors and System Redesign

3. Preventable DEATHS 44 - 98,000 2-20 errors/near misses per patient/day Only 1-10% errors reported Most are system flaws causing human error System flaws go unexamined unless there is concern for “significant” injury Preventable errors continue to occur Preventable costs $17 - 29 Billion Current Climate in ‘Patient Safety’

4. In 2000, Upper Chesapeake Health initiated a system-wide Patient Safety Team Key Aims included: -Coordinating the Patient Safety Effort -Promoting a non-punitive culture -Develop and conduct organization-wide assessment of safety practices (VHA tool) - Improving data collection and analysis of adverse events and near misses What UCH has Been Doing

5. Our Achievements Developed and implemented the following: -Patient Safety Plan, integrated system-wide -Centralized Patient Safety Committee -Departmental Case Study - a “process” review -The Good Catch - A proactive reporting component in the online Event Tracking System -Departmental Risk Self-Assessments -Quality Council “Report Card” to track accomplishments of department specific safety indicators -Track Performance Evaluation Scores for “Safety Standard” -Integrating patient safety initiatives into our existing Rewards and Recognition program

6. What’s Next?

7. A Good Catch is reported when there exists hazardous conditions or a set of circumstances that may lead to patient or injury, if the process is left unchanged Good Catch Reporting

8. The Case Study is designed as a teaching tool developed to broaden the frontliner’s understanding of, and practice with, a “process” review approach to error … which in turn furthers efforts towards a non-punitive safety culture Case Study Program

9. Obtain the Facts Present case to team Explore the Process(es) involved Brainstorm for opportunities to improve Develop an action plan with follow-up built in Basic Principals

10. Frontliners can analyze or design processes that will be safe and effective by understanding basic concepts of human behavior

11. Human Error in Medicine Human Error is simply defined as an inappropriate or unintended act giving rise to an unintended outcome. The key however, are the circumstances that surround and impact the act.

12. Human Errors Occur Because of… Inattention Interruption Memory Lapse Communication failures Poorly designed equipment Environmental influences (lighting, noise) Knowledge deficit Fatigue Etc…

13. Principals of Human Errors Human Factors Engineering or Ergonomics Systems Analysis Cognitive Science

14. Human Error Defined Cognitive Concepts Slips, Lapses and Mistakes Skill based, Rule based and Knowledge based

15. The Freudian Slip Slips and Lapses Actions not in line with your intentions, execution errors … hence the term “Freudian slip” Mistakes Resulting from a wrong plan of action triggered by lack of knowledge, misinterpretation of the problem or bad habit.

16. Skills Rules and Knowledge Skills-Based = slips and lapses: You know what your doing, but the actions don’t go as planned Rules-Based = mistakes: You think you know what your doing, but fail to notice contraindications, apply a bad rule or fail to apply a good rule Knowledge-Based = mistakes: Your not really sure what you’re doing, lack of sufficient knowledge

17. Active and Latent Failures When considering the human contribution to system failures distinguish between Active and Latent Failure Active Failures occur immediately Latent Failures lie dormant until the surrounding circumstance trigger the failure

18. Humans vs. The System Characteristics of high risk processes that can lead to human failure Complexity Forced reliance on memory or vigilance Variable input / Inconsistency Human intervention Time constraints Hierarchical culture

19. A Path to Failure Latent CurrentActive Failures Conditions Failures Defenses ACCIDENTACCIDENT Cognitive Failures (Memory Lapses) Slips Mistakes Workload Equipment Knowledge Ability Environment Manufacture Design Management Decisions Policy

20. Faulty Process/System Design Creates Circumstances Which Contribute to Human Error Makes Errors Difficult to Detect Makes Detected Errors Difficult to Reverse What can be done….?

21. Failure Mode Effects Analysis The FMEA is a systematic method of identifying and preventing process failures. The FMEA is aimed at pre-event circumstances in an effort to predict and prevent injury caused by a system’s failure to support the human element.

22. Why FMEA? FMEA examines a process to identify potential errors and determine possible effects. It is a team-based, systematic, proactive approach to identifying the ways a process or design… …can fail …why it might fail …how it can be made safer

23. What is FMEA? Failure A System or Process performs in an undesirable or unintended way Mode The ‘way’ in which the failure is caused to occur (contributing factors) Effects The result or consequence of the failure Analysis Detailed examination of the elements and structure of a process

24. How to FMEA 1.Identify what broke down, what steps failed… Consider: - Human limitations - Equipment issues - Department interactions 2.Identify what could have prevented the breakdowns from occurring…Consider: - fail-safes for human limitations 3.Identify what can improve the process… Develop: - an item by item action plan The Key Is To Be Thorough!

25. 7 Simple Steps in Applying FMEA 1.Select a Process 2.Understand the Current Process –Flow Chart by practice (not policy) 3.Identify Potential Failure Modes –List Causes (Contributing Factors) 4.Calculate Priorities of each Cause 5.Develop Recommendations to Reduce Reoccurrence 6.Implement the Action Plan 7.Measure your Success

26. When to Use the FMEA Case Study - Triggers ETS – Good Catch Benchmarking industry trends Sentinel Event Alerts Team Member concerns Patient Complaints Patient Care – Near Misses History of Adverse Events Literature identifies as High Risk Characteristic of High Risk Process New Process Proposed Redesign

27. Measure your Success Your Action Plan should Include follow-up mechanisms, automate when able Clearly define what, when and how to measure Clearly define expectations and accountability Clearly define reporting structure of various groups Look to outside resources for assistance when you reach barriers This shouldn’t be a burden, publicize your success and set backs to validate the effort….Stay the Course

28. Tools Available to You Good Catch Reporting (ETS) Case Study Program Failure Mode Effects Analysis Root Cause Analysis And… Healthcare Case Study FMEA

29. FMEA Table Process Steps Pain Assessment Process Failure Modes Causes Effects Possibility 1=remote 5=can occur 10=certain to occur Severity 1=no harm 5=may affect pt adversely 10=injury or death will occur Detection Before event takes place 1=will always be detected 5=might be detected 10=detection not possible Criticality (Mean of Poss, Sev, Det) 1=no action nec 5=action must be considered 10=action a must Step 1: Assess Patient FM: Inaccurate pain assessment C: Cultural influences Patient unable to articulate Eff: Poor pain control 5 5 5 5

30. Patient Safety We’re all in it together! Recognize Human Factors and the Impact on Processes Incorporate these Concepts into your Daily Routine Utilize the Tools Available Call on Resources such as the Risk Management Dept UCH Service Standards Safety, Courtesy, Efficiency and Environment