f5c

Information about f5c

Published on June 26, 2007

Author: Sabatini

Source: authorstream.com

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Patient Safety Research Efforts in the US:  Patient Safety Research Efforts in the US Danish Society for Patient Safety June 12, 2002 Annual Accidental Deaths:  Annual Accidental Deaths Examples of Popular Press Headlines:  Examples of Popular Press Headlines Institute of Medicine Report:  Institute of Medicine Report Four-tiered approach to reducing medical errors Establish national focus on patient safety Identify and learn from medical errors through mandatory and voluntary reporting systems Raise standards and expectations for improvement through oversight, group purchasers, professional groups Implement safe practices at the delivery level Public - private partnership! Iatrogenic Injury/Harm:  Iatrogenic Injury/Harm An injury or harm to a patient attributed to the process of care rather than underlying physiological conditions Hazard:  Hazard Anything which has the potential to cause harm Risk:  Risk The likelihood that somebody or something will be harmed by a hazard, multiplied by the severity of the potential harm Error:  Error The failure of a planned action to be completed as intended or the use of a wrong action to achieve an aim. Errors can include problems in practice, products, procedures, and systems. Goals of Patient Safety:  Goals of Patient Safety Reduce the risk of iatrogenic (caused by treatment) injury to patients Remove or minimize hazards which increase risk of iatrogenic injury to patients Risk Management:  Risk Management To make health care safer we must focus on risk to patients We must move away from traditional focus on limiting the risk to the institutions We cannot keep hiding events and known patient safety hazards deeper and deeper in the cave of our own self deception Congressional Action:  Congressional Action AHRQ designated as lead agency for patient safety research Congress appropriates $50 million in FY 01 and $55 million in FY 02 ($60 million in FY 03 administration budget for patient safety research and development Congressional Intent:  Congressional Intent Funds should be used to: Develop guidelines on the collection of uniform data related to patient safety. Establish a competitive demonstration program for health care facilities and organizations to test best practices for reducing errors. Determine ways to improve provider training in order to reduce errors. Congressional Intent:  Congressional Intent Competitive demonstration program for health care facilities and organizations to: Determine the causes of medical errors. Develop replicable models that minimize the frequency and severity of medical errors. Develop mechanisms that encourage reporting, prompt review, and corrective action. Develop methods to minimize any additional paperwork burden on health care professionals. Congressional Intent:  Congressional Intent Health systems and providers participating in this demonstration program should utilize all available and appropriate technologies to reduce the probability of future medical errors. Systems-related Best Practice RFA: 12/99:  Systems-related Best Practice RFA: 12/99 David bates, Brigham and women's hospital, improving safety by computerizing outpatient prescribing Harry Selker, new England medical center, TIPI systems to reduce errors in emergency cardiac care Eric Thomas, university of Texas health science center, Houston, teamwork and error in neonatal intensive care Steven Woolf, Virginia commonwealth university, characterizing medical error: a primary case study Colin MacKenzie, university of Maryland, brief risky high benefit procedures: best practices model Mark McClellan, Stanford university, developing best practices for patient safety Significant Inputs Into AHRQ’s Patient Safety Agenda:  Significant Inputs Into AHRQ’s Patient Safety Agenda Reauthorization language Appropriation language and Intent of the Congress NAC Input Ongoing interaction with national organizations and partners (QuIC, NPSF, NCCMERP, GIH, etc.) and international partners (Australia and the UK) Major Themes Identified in the Patient Safety Research Agenda:  Major Themes Identified in the Patient Safety Research Agenda Epidemiology of Errors Infrastructure to Improve Patient Safety Information Systems Knowing Which Interventions Should be Adopted Facilitating the Implementation of What is Shown to Work in Improving Safety Disseminating Information to Clinicians, Policymakers, Patients, and Others AHRQ Patient Safety RFAs:  AHRQ Patient Safety RFAs 1) Health System Error Reporting, Analysis, and Safety Improvement Demonstrations 2) Centers of Excellence for Patient Safety Research and Practice 3) Developing Centers for Patient Safety Research and Practice 4) Clinical Informatics to Promote Patient Safety (CLIPS) 5) Effect of Working Conditions on Patient Safety 6) Patient Safety Research Dissemination and Education Supporting Demonstration Projects:  Supporting Demonstration Projects What information should be collected? How? How can the data be used to improve safety? 24 demonstration projects awarded totaling $24.7 million to examine data collection, analysis and use public, disclosed error reporting systems confidential error reporting systems analysis of administrative data, malpractice claims Includes projects to look at changes in information systems to improve data collection Examines Some State Based Systems Using Computers and Information Technology to Improve Safety:  Using Computers and Information Technology to Improve Safety How can computers and information technology be applied to reduce errors and improve quality of care? 22 projects totaling $5.3 million to develop and test state-of-the-art applications hand-held computers with decision support systems simulation tools to train clinicians and to identify and analyze near errors and near misses examine how to improve specific tools like errors in the use of infusion pumps Working Conditions and Patient Safety :  Working Conditions and Patient Safety What is the impact of working conditions in health care settings on patient safety? 8 projects totaling $3 million to examine issues such as staffing, fatigue, stress, and sleep deprivation and their relationship to medical errors assessing the relationship between daily changes in the working conditions in hospital, including nurse staffing, ratios, workload, and skill mix study issues that have been examined extensively in aviation, manufacturing, and other industries, but not in health care Developing and Encouraging Centers of Excellence in Patient Safety:  Developing and Encouraging Centers of Excellence in Patient Safety How can new and existing centers be created and supported to help carry out patient safety research? 23 projects totaling $8 million to foster innovative approaches to improving safety at facilities and organizations in diverse locations across the country examining how to improve teamwork among health care professionals how to apply lessons from crew resource management in aviation to create stronger teamwork in health care Disseminating Research Results :  Disseminating Research Results What are the best ways to educate clinicians and others about the results of patient safety research? 7 projects totaling $2.4 million to develop, demonstrate, and evaluate new approaches to improving provider education applying new knowledge on patient safety to curricula development, continuing education, simulation models, and other training strategies Identify Proven Patient Safety Practices:  UCSF-Stanford EPC commissioned by AHRQ reviewed evidence on safety practices engaged 39 authors at 11 universities reviewed more than 3,000 pieces of literature from medicine, aviation, human factors and other fields 'endorsement' issue LACK OF EVIDENCE VERSUS LACK OF EFFECTIVENESS full report available through www.ahrq.gov Identify Proven Patient Safety Practices Other Activities:  Other Activities Institutive of Medicine developing patient safety data guidance Implementation plan for integrating reporting systems Evaluating medical team training efforts of the US Department of Defense Develop cultural assessment instruments Planning a patient safety corps training program New Initiatives for FY 03:  New Initiatives for FY 03 Integrate US Government event reporting systems Establish a patient safety program evaluation center Implement the patient safety improvement corps training program Issue challenge grants for institutions to implement best practices in patient safety Collaborative research program with UK Event Reporting Issues and Concerns, US Activities:  Event Reporting Issues and Concerns, US Activities Danish Society for Patient Safety June 12, 2002 Errors are Useful Information:  Errors are Useful Information We learn more from our failures than we may from success 'Give me a fruitful error anytime, full of seeds, bursting with its own corrections. You can keep your sterile truth for yourself' - Vilfred Pareto Can improve our process when studied No harm and near miss events may predict disasters or bad outcomes Medical Errors are not Unique:  Medical Errors are not Unique Share important causal factors with those in other complex systems Transportation Aviation Railroads Automobiles Nuclear power Petrochemical Industry Event:  Event Is a deviation in an activity or technology that leads toward an unwanted negative consequence (Freitag and Hale) Adverse medical events are the unwanted consequences (harm to a patient) resulting from the process of care Event Types:  Event Types A sentinel event/misadventure is an event in which death or harm to a patient or harm to the mission of the organization has occurred. A no-harm event is an event that actually occurred but resulted in no actual harm although the potential for harm may have been present. Lack of harm may be due to the robust nature of human physiology or pure luck. An example of such a no-harm event would be the issuing of an ABO incompatible unit of blood for a patient, but the unit was not transfused and was returned to the blood bank. A near miss, as defined by Van der Schaaf, (3) is an event in which the unwanted consequences were prevented because there was a recovery by identification and correction of the failure, either planned or unplanned. Iceberg Model of Accidents and Errors:  Iceberg Model of Accidents and Errors Misadventure Death\severe harm No Harm Event Potential for harm is present Near Miss Unwanted consequences were prevented because of recovery Actually Occurred Recovery Actual Harm Heinreich’s Ratio1:  Heinreich’s Ratio1 1 major injury 29 minor injuries 300 no-injury accidents 300 1 It has been proposed that reporting systems could be evaluated on the proportion of minor to more serious incidents reported 2 2. An Organization With a Memory, A report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer, The Stationary Office, London 2000 1. Heinreich HW Industrial Accident Prevention, NY And London 1941 29 Reason’s Types of Failures and Conditions:  Reason’s Types of Failures and Conditions Categories based on who initiated the failure and how long it takes to have an adverse effect Active are failures committed by those in direct contact with the human-system interface (human error) Latent conditions are the delayed consequences of technical and organizational actions and decisions Sharp End - Active Failures:  Sharp End - Active Failures Individuals at the sharp end are in direct contact with the human-system interface. They administer care to patients. Their actions and decision may result in active failures. Sharp End Rasmussen’s Modelof Human Failure:  Rasmussen’s Model of Human Failure Skill based behavior Rule based behavior Knowledge based behavior Skill Based Behavior:  Skill Based Behavior Perform routine tasks e.g. Driving while listening to the radio, holding a conversation Rule Based Behavior:  Rule Based Behavior Perform familiar tasks, experience e.g. approach familiar stop sign access stored info = slow car down, look both directions, etc.. Knowledge Based Behavior:  Knowledge Based Behavior Knowledge based behavior Novel situation, problem solving at conscious level e.g. traffic lights broken at busy junction Consciously generate solution Proceed or stop Blunt End - Latent Conditions:  Blunt End - Latent Conditions Individuals at the blunt end take actions and/or make decisions that affect technical and organization policy and procedures and allocate resources. Their actions and decisions may result in latent conditions. Blunt End Misadventures Happen:  Latent Active Failure Failure Misadventures Happen Blunt end actions and decisions create latent underlying conditions Sharp end actions and decisions create active human failure Misadventure + Slide42:  J.Reason, BMJ 2000;320:768-770 The Swiss Cheese Model of System Accidents Titanic:A Classic Case Study of Latent Conditions:  Titanic: A Classic Case Study of Latent Conditions Titanic Latent Conditions:  Titanic Latent Conditions Inadequate number of lifeboats No transverse overheads on water tight bulkheads No shake down cruise to train crew No training for officers on handling of large single rudder ships Only one radio channel Generation of Latent Conditions:  Generation of Latent Conditions The higher up the organization ladder that an individual is, the greater their capacity to generate latent conditions (JT Reason 1994) Lack of adequate lifeboats was the single greatest cause for the loss of life on the Titanic White star line CEO, Bruce Ismay, made the decision about the life boats Someone’s Got to Pay - Blame:  Someone’s Got to Pay - Blame The Human Factor Myth:  The Human Factor Myth 'The way to eliminate errors is to require perfect performance.' Error free performance enforced by punishment has been the traditional in medicine. Errors are made by individuals, but individuals work within systems. Slide48:  Perfectionism You have had three reported errors Off With Your Head Encouraging Improvement? Blame and Train:  Blame and Train Errors as a Systems Problem:  Errors as a Systems Problem 'We must stop blaming people and start looking at our systems. We must look at how we do things that cause errors and keep us from discovering them...before they cause an injury.' (Leape 1994) The Greatest of All Evils?:  The Greatest of All Evils? The individual who does not report their error? The organization that does not learn from its mistakes? Everyone in Organization is Accountable for their Actions and Decisions:  Everyone in Organization is Accountable for their Actions and Decisions If you hold sharp end individuals accountable for their actions and decisions You must also make blunt end individuals accountable for their actions and decisions as well Reporting Errors: Role of Government:  Reporting Errors: Role of Government Public Accountability Learning from Errors Harm All Events Looking for Harm:  Looking for Harm Active Event Reporting Passive Indicators Discharge Data Passive Triggers Medical Records Truth? Purpose of an Event Reporting System:  Purpose of an Event Reporting System Useful data base to study system’s failure points Many more near misses than actual bad events Source of data to study human recovery Dynamic means of understanding system operations Features of an Ideal System:  Features of an Ideal System Confidential 'just' system Integrated into the quality assurance system of participants All events reported including near misses Events classified by What and where events happened Underlying root causes of event Data forwarded to non-regulatory central system for further analysis Data Needs of a System:  Data Needs of a System Description of event What happened Where it happened Who (type of employee) was involved Why did it happen - Cause Technical Organizational Human factors Components of a Reporting System:  Components of a Reporting System Detection Selection Description andamp; Classification Computation Interpretation Detection:  Detection Locates where andamp; when Number of barriers breached Consequences Identifies who was involved Documents recovery First Step in Error Prevention/Management:  First Step in Error Prevention/Management Detection is the first step in error management From an organizational point of view it is important that error detection rate be high Errors that are not detected can have disastrous consequences (Zapt andamp; Reason 1994) The goal of error management is to increase detection andamp; reporting rates to decrease risk Detection Sensitivity Level (DSL):  Detection Sensitivity Level (DSL) Number of events reported indicates an organization’s detection sensitivity level (DSL) High reporting rates indicate a high DSL Few events reported indicates a low DSL To achieve a high DSL an organization must eliminate impediments to reporting Confidential no fault reporting is best to encourage reporting Relationship of DSL to ESL:  Relationship of DSL to ESL DSL ESL Information Risk Slide63:  Report rate 1990-1995 andgt; 3X increase Severe/high risk - 1-6/93 to 1-6/95 2/3 decrease Experience With ASRs of BASIS INFO RISK Event Report Rate from a Hospital Transfusion Service:  Event Report Rate from a Hospital Transfusion Service Orientation Results of an Increased DSL:  Results of an Increased DSL Selection of Events:  Selection of Events Anticipated high volume of events Therefore not all events need to receive the same level of investigation Routine Classified Logged Trended Corrected Expanded Investigation:  Expanded Investigation Action Decision Table Causal analysis of new events Develop Causal Trees 10% of known events analyzed Investigation:  Investigation Define the event Identify who was involved Get detailed information on antecedents When? Where? What? Why? Slide69:  When? What? Where? Who? Gather Data And Why? (And) Why? Why? And Why? Building a Causal Tree:  Building a Causal Tree Based on Fault Trees Investigation quality critical Event at the top Two parts: failure and recovery side Chronological evolution of antecedents Ask 'why' to get next antecedent Logical relationship of antecedent actions and decisions Slide71:  Causal Tree Event Primary recovery action to stop adverse outcome Primary action or decision Primary action or decision Root Cause Failure side Recovery side Antecedent recovery action and Antecedents Antecedent recovery action and and Root Cause Root Cause Codes Description (What & Where):  Description (What andamp; Where) Coding system derived ICD codes Reduces the need for narrative Uniform description of events Eindhoven Classification System:  Eindhoven Classification System 20 codes divided in: Technical Factors Organizational Factors Human Factors Knowledge Based Rule Based Skill Based Other Factors Patient Related Factors Unclassifiable Technical (Latent):  Technical (Latent) Technical TEX External TD Design TC Construction TM Materials Organizational (Latent):  Organizational (Latent) Organizational OEX External OK Transfer of Knowledge OP Protocols OM Management Priorities OC Culture Human Factors (Active):  Human Factors (Active) Skill Based HSS Slip HST Tripping Rule Based HRQ Qualifications HRC Coordination HRV Verification HRI Intervention HRM Monitoring HEX External Knowledge Based HKK Knowledge Other Factors:  Other Factors Other PRF Patient Related Factor X Unclassifiable Slide78:  First Question Second Question Third Question A Transfusion Error (labeling):  A Transfusion Error (labeling) Medical Technologist on the 2nd shift was releasing blood units from quarantine to inventory noticed an out-of-sequence transfer label numbered on a unit of red blood cells (rbc). Actions taken: notified supervisor immediately. Unit isolated until labels corrected A Labeling Error:  A Labeling Error Back of Unit Front of unit Xerox of blood unit labels Failure: Labeling Sequence:  Failure: Labeling Sequence 'Labels for each bag are to be separated by tearing at marked brackets...' Slide82:  Causal Tree Unit of RBC almost released with out-of-sequence transfer label # Unit isolated until label corrected Labeling inadequately checked Phlebotomist tore label in wrong place Label had poor separation markings Failure side Recovery side 2nd shift Tech. saw label error and OP Notified supervisor TD TD and and Inadequate SOP for checking label Label provided poor feedback HSS Correction of Label Error:  Correction of Label Error Current Patient Safety (Adverse Event) “System”:  Reporters Providers Hospitals Clinics Outpatient Care Facilities Long Term Care Facilities Home Care Agencies Health Plans Required States Federal Agencies Accreditors Ad Hoc Federal Agencies Internal Quality Programs Peer Review Organizations Insurers / Risk Managers Purchasers Etc. etc. etc. Current Patient Safety (Adverse Event) 'System' Current Patient Safety Data Flow:  Users Hospitals Clinics Doctors office’s Long term care Managed Care Organization 1 2 3 4 5 6 7 8 FDA CDC Accreditors CMS State AHRQ Researchers Policy Makers Current Patient Safety Data Flow Vision:  Vision The Patient Safety Network is a knowledge system for accumulating, exchanging and integrating relevant information about and resources among private and public stakeholders to protect patients and healthcare personnel, and promote patient safety. PSN Concepts:  PSN Concepts Knowledge system for patient safety is essential Local user relevance is essential; all participants should benefit Integrated system is essential Includes state / federal required reports Standardized methods / definitions Compatible with existing systems Modular system is optimal Evolution Expansion PSN Harm Data:  PSN Harm Data Incidents (numerator) – targeted injury or harm / adverse events where 'zero events' is the goal Never events Sentinel events Unusual events Rates (numerator / denominator) 'best possible rate' is the goal; 'zero events' not realistic (at least yet) Benchmarks Performance measures Lessons learned PSN No Harm Near Miss Data:  PSN No Harm Near Miss Data Increase information about potential risks and hazards Prioritize by risk Reduce risk over time Increase or maintain reporting levels Development Steps:  Development Steps December 2000 Preliminary input form user March 2001: Input from experts PSN Vision / goals reality check PSN system content Marketing issues April 2001 Data Summit: Input and marketing September 2001 Awarded a contract implementation planning to MEDSTAT June 2002 MEDSTAT issued report PSN Input Content:  PSN Input Content Core Components with integration and standardization Required information / external reports States Federal agencies Accreditors Others Recommended consensus content (future?) Optional Components Ad hoc components National Patient Safety Network::  FDA HCFA CDC AHRQ Common User Interface Data Modules National Patient Safety Network: National Patient Safety Network::  Common User Interface PSTF Data Modules National Patient Safety Network: Shared Data Warehouse Public Access Non-federal Data Pools* *Non-federal Data Pools State / Local Health Departments Peer Review Organizations Other Contractors ? Accreditors USERS Next Steps:  Next Steps Issue an RFP July 2002 Award contract on or before 29 September 2002 Begin the system in FY 03 on a pilot basis Full operation FY 04/05 Anticipated Outcomes:  Anticipated Outcomes DSL goes up and stays up Over time the Event Severity Level (ESL) goes down Identify where process errors occur (Black Spots) Identify system critical failure points (Barrier Analysis) Identify common causal factors Monitor changes in the system Detection Sensitivity Level:  Detection Sensitivity Level Organization that encourage reporting through confidential, no fault reporting find that: That people are more than willing to report There is often is a ten fold or greater increase in reporting The more feedback provide the more reports are generated Event Severity Level (ESL):  Event Severity Level (ESL) Initially there is an increase in the severity of the events reported Confessional stage Over time the ESL will decline Exxon Nuclear Power Managing Error:  Managing Error Identify system weak points before adverse events occur Report Near Miss Events Encourage reporting Look for root causes Avoid blame and train Fix the things that set up humans for failure Need for Collaboration:  Need for Collaboration Opportunity to share data Need international standards and data structures IOM Data Guidance Study US / UK collaborative efforts European and other international collaboration? All patient safety is Local:  All patient safety is Local As Tip O’Neal once said 'all politics is local' Patient safety is a local issue Federal/State government can facilitate Individual health care providers and institutions make patient safety everyday We can make health care safer for our patients :  We can make health care safer for our patients Identify system weak points before adverse events occur Report Near Miss Events Encourage reporting Look for root causes Avoid blame and train Fix the things that set up humans for failure Thank You:  Thank You James B. Battles, Ph.D Senior Service Fellow for Patient Safety Agency for Healthcare Research and Quality Center for Quality Improvement and Patient Safety 6011 Executive Blvd Suite 200 Rockville, MD 20852 Phone: 301-594-9892 Email: [email protected]

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