1. Patient Safety Vince Watts, MD, MPH

2. Topics Patient Safety –Overview –Tools –Emerging issues Change –Theories/models of change –How to lead change

3. Where are we coming from?

4. “First do no harm” Worthington Hooker, 1849 “…the first requirement of a hospital is that it should do the sick no harm” Florence Nightingale, 1863

5. End Results Hospital Earnest Codman 1911-1915 Boston –Errors due to lack of technical knowledge or skill –Errors due to lack of surgical judgment –Errors due to lack of care or equipment –Errors due to lack of diagnostic skills –The calamities of surgery that are beyond our control

6. Eli Schimmel Annuals of Internal Medicine 1964 –Examine iatrogenic harm at Yale University Medical Center –1960-1961 –20% of admissions were injured –The length of stay was 140% greater in those who were harmed –4% severely injured or killed

7. Jeff Cooper Biomedical Engineer Hired at Mass General to assist with anesthesiology research “Preventable anesthesia mishaps: a study of human factors” Anesthesiology 1978 **Led to widespread changes in the field..starting in 1994**

8. To Err is Human Institute of Medicine Report Medical errors kill more people than breast cancer or AIDS

9. Adverse events in healthcare 1 in 20 Ways to Go from National Geographic Magazine 2006 Note: Data for adverse events added to graphic.

10. Elizabeth McGlynn Population based survey New England Journal 2003 “the average American receives about ½ the most basic routine healthcare”

11. Safety and Quality

12. Immediacy Causality Safety Quality

13. Where are we now?

14. Understanding how things go wrong

15. Patient Safety – Human Error Technical Individual Team Profession Institution Policies/Procedures Accident LATENT FAILURES DEFENSES Incomplete procedures Regulatory narrowness Mixed Messages Production pressures Responsibility shifting Inadequate training Attention Distractions Clumsy Technology Deferred Maintenance

17. Two views of how to improve patient safety

18. Design, Technology, and Standardization Human Factors Engineering Computerized Support Standardized Procedures

19. A surgical safety checklist to reduce morbidity and mortality in a global population. Haynes ABHaynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group.Weiser TGBerry WRLipsitz SRBreizat AHDellinger EPHerbosa TJoseph SKibatala PLLapitan MCMerry AFMoorthy KReznick RKTaylor BGawande AASafe Surgery Saves Lives Study Group

20. People make safety Culture of safety Training for procedural skills Teamwork and communication

21. Association between implementation of a medical team training program and surgical mortality. Neily JNeily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP.Mills PDYoung-Xu YCarney BTWest PBerger DHMazzia LMPaull DEBagian JP

22. Developing Effective Solutions

24. Unintended Consequences of “ Obvious ” Interventions Forklift story –Workers getting hit in loading dock area –Rusty vehicles painted, alarms turned up –No decrease in collisions, why?

26. Patient Safety - Human Error Process Design & Organizational Change Process Design –Reduce Reliance on Memory & Vigilance –Simplify –Standardize –Checklists –Forcing Functions –Eliminate Look and Sound-alikes Organizational –Increase Feedback –Teamwork –Drive Out Fear –Leadership Commitment –Improve Direct Communication

27. Why are we here today?

28. IOM Goals Crossing The Quality Chasm Safe Timely Efficient Effective Equitable Patient-Centered

29. Patient care (compassionate, appropriate, effective) Medical knowledge (biomedical, clinical, cognate sciences, and their application) Practice-based learning and improvement (investigation and evaluation, appraisal and assimilation of evidence) Interpersonal and communication skills (effective information exchange, teaming with patients and families) Professionalism (carrying out professional responsibilities, ethics, sensitivity) Systems-based practice (awareness and responsiveness to larger context and system of health care, use of system resources)

30. Berwick “lessons” Error is not the problem, harm is the problem Rules don’t create safety, rules and breaking rules creates safety We don’t have reporting to measure progress, we have reporting to understand stories Communication (not technology) is mainstay of safety

31. Berwick “lessons” Healthcare is different from other industries What happens after an injury is as important as what happens before the injury

32. QUESTIONS?