Casting the Safety Net – Fish or Cut Bait?

Capturing Precursor Safety Events

Indiana Association for Healthcare Quality

2010 Annual Conference

April 30, 2010

Martha Boutin White, RN, BSN, MBA,

Patient Safety Officer

Memorial University Medical Center

Savannah, GA

Sherry L. Sweek, RHIA, CPHQ, CPMSM,

Director of Quality Improvement

Southeast Georgia Health System

Brunswick, GA

Objectives

• Define Precursor Safety Events including errors of omission

• Explain leverage points introduced to increase reporting and decrease errors

• Share results and data analysis

• Review lessons learned

• Discuss next steps and recommendations

Overview• Memorial’s safety journey

• 2008 Safety refocus

• Precursor safety events project

• How we got started

• Problems we encountered

• Current safety performance

• Next steps

Memorial University Medical Center• Two-state healthcare organization servicing a

35-county area in southeast Georgia and southern South Carolina

• Four-year medical school on campus affiliated with Mercer University School of Medicine

• 530-bed tertiary hospital with Core Services:– Level 1 Trauma Center– Level 3 Neonatal Intensive Care Nursery– Heart & Vascular Institute– Curtis & Elizabeth Anderson Cancer Institute – George & Marie Backus Children’s Hospital– Rehabilitation Institute

Off Course: An Alarming Trend in 2002Overall (Near Miss + Sentinel Event)Trend

1998 1999 2000 2001 2002 2003 2004

# of

Eve

nts

Actual

Best-fit Trendline

Gaining Direction in Our Safety Journey• Conducted Mandatory Error Prevention Training (Team

Members, Team Leaders and Physicians)• Enhanced Analysis of Events (Root Cause / Common Cause)• Established and Enforced “RED Rules” for Operating Room,

Invasive Procedures, and overall Hospital Global “RED Rules” • Implemented Incident Scoring System (Compliance & Patient

Outcome)• Incorporated Increased Reporting Metric (ROSI) in Team Leader

Bonus Structure• Created Safety Coach Program and Dedicated FTE Positions

We Thought We Had The Right CoursePreventable Sentinel Event Trend

0

1

2

3

4

5

6

7

8

9

10

1998 1999 2000 2001 2002 2003 2004 2005

Actual

Best-fit Trendline

89% Reduction

NOTE: p=0.016 (2002 vs 2003). A p value >0.05 is considered

Straying Off Course: 2006-2007• Dealt with OIG Investigation for Alleged Stark Violations and 22

surveys in an 18 month time period• Observed 31% Decreased Incident Reporting• Discounted Increased Sentinel Events Due to Joint Commission

Definition Changes• Failed to Recognize System Wide Issues and Implement

Changes• Experienced Instability with Loss of Patient Safety Officer, COO,

CNO, CFO, Director of Quality, VP of Quality and Patient Safety• Moved Away from Safety to Financial Situations by All Leaders• Not Cognizant of the Impact of Financial Woes on Safety

Memorial Health SSE Rate 2002 to January 2008

Jan 02 May 02 Sep 02 Jan 03 May 03 Sep 03 Jan 04 May 04 Sep 04 Jan 05 May 05 Sep 05 Jan 06 May 06 Sep 06 Jan 07 May07 Sep 07 Jan 08

SS

E R

ate

Stage 1:Good Operations

Stage 2: Self Satisfaction

Stage 5: Collapse

Stage 3: Blindness

Stage 4: Denial

Create a Safe Day

MUMC Organizational Complacency

When Did We Fish?

Serious Safety Event Rate (SSER) for MUMC2005 - Present per adjusted 10,000 patient days

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00Jan

2005

Feb 2

005

Mar 2

005

Apr 2

005

May 2

005

Jun 20

05Jul

2005

Aug 2

005

Sep 2

005

Oct 2

005

Nov 2

005

Dec 2

005

Jan 20

06Fe

b 200

6Ma

r 200

6Ap

r 200

6Ma

y 200

6Jun

2006

Jul 20

06Au

g 200

6Se

p 200

6Oc

t 200

6No

v 200

6De

c 200

6Jan

2007

Feb 2

007

Mar 2

007

Apr 2

007

May 2

007

Jun 20

07Jul

2007

Aug 2

007

Sep 2

007

Oct 2

007

Nov 2

007

Dec 2

007

SSE Ra

te

0

1

2

3

4

5

# SSE

Serious Safety Events

Serious Safety Event Rate for MUMC

Total Time to Complete a Root Cause Analysis

• Determination of SSE – 6–8 hours (x2)• Communicating to stakeholders - 6• Charter – 1 hour• Interviews – 1 hour each (x10x3)• Swiss Cheese diagram – 1 hours• Task Analysis – 3 hours• Event Time Line – 2 hours (x2)• Team Meetings – 2.5 hours each (x8x3)• Report Completion – 2 hours• Pre-report with Champion – 1 hour (x3)• Presentation of Report – 1.5 hours (x4)• Coding the event in database – 1 hour

Total: 133 hours/month

“We’re gonna know all there is to know about the PSE business”

Serious Safety EventVariation in standard of careReaches the patientDeath or major harmCause Analysis Level: RCA

Precursor Safety EventVariation in standard of careReaches the patientMinimal or no harmCause Analysis Level: ACA

Near MissVariation in standard of careDoes not reach the patientCause Analysis Level: Trend, ACA

PrecursorSafetyEvents

SeriousSafetyEvents

Near Miss

SafetyEventClassificationSEC

SM

What is a Precursor Safety Event?

• A precursor safety event is a variation in care that reaches the patient but does not cause permanent harm

• Delay in treatment • Failure to recognize• Improper Pt ID• Inadequate check• Inadequate handoff• Inadequate monitoring• Missed medication• Missed treatment• Omitted Action• Wrong dose• Wrong medication given • Wrong treatment

Redirecting the Focus to Prevention

Physician writes

ambiguous order

Pharmacist enters

wrong dose

Nurse administers 10X dose (medication overdose)

Pharmacy Tech fills order

SSE

PSE

NMNM

NM

Nurse skips chart check

Barriers to Harm

Did We Have the Right Equipment?

• License – Approval of Quality & Patient Safety Committee and Board of Directors to fish for PSEs

• Net – Decree to increasing the number of incident reports became a strategic objective

• Bait – Rewards for Safety Saves • Catch – Precursor Safety Events with

coded information to drive improvement

We Bought a Trawler...on Credit

We Pulled Up Full Nets

• 2009: 8,509 incidents, 2 Serious Safety Events– 709 incidents per month– 210 incidents per month visitor issues,

workers comp or physician complaints– 144 incidents per month near misses– 355 PSEs per month

• Everyone gets to eat….

Beware of Shifting Tides

• Fishy Headlines – Paradigm Shift Required– Risk Management Shares Information and

Promotes Transparency – No Compass on How to Navigate– Internal Sonar Better Than Nothing

Risk Throws in a Flotation Device

• Began Weekly Meeting with Risk – Review Precursor Safety Events – Verify Profession Involved– Define Inappropriate Act – Determine Apparent Cause Reports– Code Completed A/C reports– Review Safety Saves for PSEs

Back on Dry Land…

• Assign Apparent Cause Reports in Safety Database

• Have Management Engineers Customize Database to House PSE information

• Compile Safety Saves and Produce Certificates

What’s Our Catch?

Is It a Keeper?

• WHEN I HAD FINISHED, I BROUGHT pt. N WAS NO LONGER WITH PT AND PT WAS NOT MONITORED. PT INITIALLY CAME TO ER FOR TRAUMA TO FACE/HEAD FROM FALL. PT WAS NOT AWAKE, OR COMMUNICATIVE WITH ME WHEN I BROUGHT HER TO THE SCANNER. I WAS ABOUT TO GET ASSISTANCE WITH MOVING THE PT WHEN SHE coded

We Fish, They Feast

• Generated Department Specific PSE Report

• Included PSE Reports to Senior Leadership Rounds

• Send PSE Reports to Managers, Directors and Safety Coaches

• Modified PSE Report Format to Incorporate Voice of Customer

Man Overboard!!!

• Hard to Stay the Course When Everyone Wants to Change Direction

• Teach Them to Fish, Teach Them to Fish, Teach Them to Fish

• Safety Drills– Swiss Cheese of Errors– Reinforce Error Prevention Techniques– Required Actions from Senior Leadership,

Directors, Managers

I Caught a Fish This BIG…

• Added PSE to Monthly Dashboard

• Established Procedure for Accountability for Apparent Causes Completion

• Determined Frequency of PSE Report to Quality Oversight Committee and Board of Directors

• Conducted and Presented Common Cause Analysis Based on PSE Data

My Fish is Bigger Than That

• Safety Rounding Tool Modified Each Month Based on Data from PSEs– STAR (Stop, think, act, review)– Safety Huddles– Patient Identification

• Pre Rounding Huddle for Unit Specific Trend or Unresolved Issues

• Behavior Based Monitoring Compliance Included on Report and in Dashboard

We Confirm Tears in The Nets

Looking First for Tears in The Net• Included data from October 2008 through May 2009• Data used to generate reports for Patient Safety

Rounds• 734 Precursor Safety Events

– 869 Inappropriate Acts– Majority of Inappropriate Acts are committed by “Sharp

End” care givers• All PSE’s coded based on event description and

additional investigation emphasizing coding data from: – Apparent Cause Reports – Level 1 or Level 2 PSEs (temporary or minor harm)

• 70% of PSEs only partially coded due to incomplete information

% of PSEs Related to Medical Errors

40.32%

62.50%

45.90%

34.12%27.40%

22.43%18.75%

37.50% 36.47% 33.33%

42.68%

0%

20%

40%

60%

80%

100%

Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09

Month

% o

f Err

ors

Mine DataA/C reports

Data & A/C

Approval for6 mth study

PSE Report & Rewards

MAXPI Saves& MAX Blitz

Comparison of Medication Errors to Medication Safety Saves

0

5

10

15

20

25

30

35

40

Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09

Month

# of E

rrors

0

2

4

6

8

10

12

14

16

18

20

# of S

afety

Save

s

Errors

Safety Saves

“PSEs are like a box of chocolates. You never know what you’re gonna get….”

The Radar Suggests…

• Sharp End Employees are Identified Most Often in Committing Inappropriate Acts– RNs, Pharmacists and Physicians

• Common Threads Among all Professional groups – S.T.A.R. (Stop, Think, Act, and Review)– Rule Based Errors (Patient ID Error)

• Limitations of The Data – Self-reported– Incomplete Data– Some Areas Still Perceive Reporting as Punitive

EPTs All Professional Groups

0

50

100

150

200

250

300

350

400

S.T.A.R. - Stop,Think, Act, Review

Check Each Other STOP whenUnsure

Adhere to RedRules and policies

Use SBAR,SHARED

CommunicationMethods

Ask Two ClarifyingQuestions

Coach Each Otherusing "ARCC"

Read Back andVerify

Inappropriate Acts

0

20

40

60

80

100

120

140

Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09

Inappropriate Acts if S.T.A.R. Utilized

0

20

40

60

80

100

120

140

Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09

STAR as an Effective Error Prevention Tool – High Risk Areas

•Above represent the units that have most frequent rounds

•L&D EPT Stop When Unsure could have prevented 9 additional PSE’s

UnitInappro.

Acts S.T.A.R.% of PSE's that could be prevented using S.T.A.R.

Pharmacy 67 43 64.2%

ED 44 15 34.1%

NICN 39 21 53.8%

PEDS 32 15 46.9%

L&D 27 4 14.8%

OR 19 12 63.1%

NICU 6 2 33.3%

TOTAL 234 112 47.9%

Mending the Nets

Charting the Course• Formed Two Ad-Hoc Teams on:

– Integrating S.T.A.R. into Patient Safety Practice

– Maximizing Report Quality in MAXPI• Team Initiatives Included on Top Ten List• Team Skippers were CNO and CFO• Development Center – Team Facilitation• Team Recommendation to Quality Oversight Committee with Implementation Plan

Stay Within the Bouys

• Added Precursor Safety Events Goals to Safety Improvement Plan

• Included PSE Metrics on Monthly Dashboard• Reported PSE Trends Quarterly to Quality

Oversight Committee and Board • Conducted annual PSE Common Cause Analysis

2009 Common Cause Navigation

• 1102 Precursor Safety Events– 1310 Inappropriate Acts– 17.5% of PSEs with Temporary or Minor Harm– Results Mirror Common Cause from August

2009– Five Straight Months with 100% of Apparent

Cause Reports Completed in Two Weeks– 35%-45% of Inappropriate Acts are with

Medication Nutrition Process– 50% of Inappropriate Acts could have been

Prevented by Using STAR

Precursor Safety Event Severity% of PSE's rated a 1 or 2 (minimal or moderate temporary harm)

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09

% 1 or 2 PSE

Linear (% 1 or 2 PSE)

PSE Error Categories

Inapp. Acts

39, 4%

976, 89%

77, 7%

Knowledge Based

Rule Based

Skill Based

PSE Professional GroupInappropriate Acts by Profession

786

96 95 71 55 36 31 30 25 28 150

100

200

300

400

500

600

700

800

900

RN Pharmacist MD Tech - Lab HUC Support MiscClinical

Therapy PCT Tech - Rad Non-Clinical

PSE Error Prevention TechniquesEPTs All Professional Groups

0

100

200

300

400

500

600

S.T.A.R. - Stop,Think, Act, Review

Check Each Other STOP whenUnsure

Adhere to RedRules and policies

Use SBAR,SHARED

CommunicationMethods

Ask Two ClarifyingQuestions

Coach Each Otherusing "ARCC"

Read Back andVerify

Nearly 50% of all inappropriate acts could have been prevented utilizing S.T.A.R.

S.T.A.R - RN

Key Processes - RN

0

50

100

150

200

250

300

350

400

Medication and NutritionProcess

Coordinating Care Patient Monitoring andAssessment

Speciman Management Admission TransferDischarge

Invasive Procedure

Utilizing STAR effectively could reduce 40% of inappropriate acts related to the medication and nutrition process.

S.T.A.R - Pharmacy

Key Processes - Pharmacy

0

10

20

30

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50

60

70

80

90

Medication and Nutrition Process Coordinating Care

Utilizing STAR effectively could reduce 68% of inappropriate acts related to the medication process.

S.T.A.R – M.D.’s

Key Processes - MD

0

5

10

15

20

25

30

35

Coordinating Care Medication and NutritionProcess

Invasive Procedure Admission Transfer Discharge Patient Monitoring andAssessment

Utilizing STAR could reduce 29% of inappropriate acts. 9 of 33 Coordinating Care issues had to do with adhering to red rules.

Casting the Safety Net

• Obtaining Right Incident Information Up Front a Challenge

• Identifying PSEs Easier Said than Done• Moving Between Risk & Quality

Databases Cumbersome• Preparing Leadership for the Number of

PSEs is Important• Taking Action on PSE Data is Key to

Making Gains on Patient Safety

Our Goal: Catch Error Before Patient Harm

Human Error

Serious Safety Event

• Let the data drive the improvements

• Apply concerted and focused effort

• Continue to raise the bar

Are We Catching Any Fish?2007 2008 2009

AHRQ Patient Safety Score

Not Collected

69% 77%

SSEs 12 4 2

SSE Rate per 10,000 Adj. Patient Days

0.45 0.18 0.08

Avg. Days Between Events

37 73 182

PSEs Not Collected

Not Collected

1102

• Insert the chart

Serious Safety Event Rate (SSER) for MUMC2005 - Present per adjusted 10,000 patient days

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00Jan

2005

Feb 2

005

Mar 2

005

Apr 2

005

May 2

005

Jun 20

05Jul

2005

Aug 2

005

Sep 2

005

Oct 2

005

Nov 2

005

Dec 2

005

Jan 20

06Fe

b 200

6Ma

r 200

6Ap

r 200

6Ma

y 200

6Jun

2006

Jul 20

06Au

g 200

6Se

p 200

6Oc

t 200

6No

v 200

6De

c 200

6Jan

2007

Feb 2

007

Mar 2

007

Apr 2

007

May 2

007

Jun 20

07Jul

2007

Aug 2

007

Sep 2

007

Oct 2

007

Nov 2

007

Dec 2

007

Jan 20

08Fe

b 200

8Ma

r 200

8Ap

r 200

8Ma

y 200

8Jun

2008

Jul 20

08Au

g 200

8Se

p 200

8Oc

t 200

8No

v 200

8De

c 200

8Jan

2009

Feb 2

009

Mar 2

009

Apr 2

009

May 2

009

Jun 20

09Jul

2009

Aug 2

009

Sep 2

009

Oct 2

009

Nov 2

009

Dec 2

009

SSE Ra

te

0

1

2

3

4

5

# SSE

Serious Safety Events

Serious Safety Event Rate for MUMC

2010 Safety Goal

Event Free Calendar

250 Days

Navigating in New Waters…

• Completed a Business Case for Safety– 68% decrease in cost of completing root cause

investigations and savings of over $100,000– Costs associated with payouts and write-offs

decreased by 90% and savings of over $400,000

• More staff time to fish because we were not spending time and effort on reactive steps for safety

• Managers able to spend time on Precursor Safety Events

“That’s all I have to say about that…”

Questions?

Sherry SweekSoutheast Georgia Health System2450 Parkwood DriveBrunswick, GA 31520912.466.2124ssweek@sghs.org

Martha WhiteMemorial University Medical Center4750 Waters Ave, Suite 451Savannah, GA 31404912.350.7569whitema2@memorialhealth.com

Contact Information