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“Create A Platform For Learning From Defects”

A CUSP Approach

Krish Sankaranarayanan MS, MBA, CPHQSenior Safety Officer- Tawam Hospital

Presented at the 2nd Annual Drug Safety MENA Summit

13 - 14 February, 2013 - Radisson Blu Yas Island, Abu Dhabi, United Arab Emirates

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Disclosure

• The presenter has nothing to disclose, nor has any commercial interest with any of those information's displayed in this presentation.

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About Tawam

• Tawam Hospital is a 477-bed tertiary care facility located in Al Ain, Abu Dhabi, and the largest of the United Arab Emirates.

• In 2006 Tawam Hospital entered a ten year affiliation with Johns Hopkins Medicine.

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Items for discussion

• Ice breaker- Eric Cropp a pharmacist, the error that sent him to prison (Video)

• Second Victim• Culture of Safety• CUSP Approach- Tawam’s experience• Learning from defects• Celebrating Safety

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Ice Breaker

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Aftermath of an error Shame & Blame

Common Response After An Error

• The types of suffering are – Increased anxiety about the future possibility of

errors, – Loss of confidence in the work they do, – Some face difficulty sleeping, – Concern about their reputation as a care giver – Reduction in their sense of job satisfaction.– Excellent clinicians may leave the profession

prematurely when involved in a preventable error.

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Medical error: the second victim..

• The term second victim was initially coined by Wu in his description of the impact of errors on professionals. The doctor who makes the mistake needs help too.

• In the aftermath of a mistake, it's important the doctor seek support to deal with the consequences.

Albert W Wu associate professorSchool of Hygiene and Public Health and School of Medicine, JohnsHopkins University, Baltimore, MD

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• Middle East: There no or lack of statistical evidence in this region to showcase patient deaths happening due to medical error

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This is what we see?

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The patients saw an average of 17.8 health professionals during their hospitalizationHow many health professionals does a patient see during an average hospitalstay? N Whitt, R Harvey, S Child

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Building a Culture of Safety

Safety Culture in High Reliability Organizations- HRO’s

Early adopters- Aviation

Definition • Safety culture is the ways in which safety is managed in the workplace,

and often reflects "the attitudes, beliefs, perceptions and values that employees share in relation to safety" (Cox and Cox, 1991).

• The safety culture of an organization is the product of individual and group values, attitudes, perceptions, competencies, and patterns of behavior that determine the commitment to, and the style and proficiency of, an organization's health and safety management. Organizations with a positive safety culture are characterized by communications founded on mutual trust, by shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. (AHRQ)

• Source: Organising for Safety: Third Report of the ACSNI (Advisory Committee on the Safety of Nuclear Installations) Study Group on Human Factors. Health and Safety Commission (of Great Britain). Sudbury, England: HSE Books, 1993.

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Culture in safe organizations• Commit to no harm • Focus on systems not people• Value Communication/teamwork

– Assertive communication– Teamwork– Situational awareness

• Accept responsibility for systems in which we work• Recognize culture is local• Seek to expose (not hide) defects • Celebrate safety

– Workers viewed as heroes

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On February 22, 2001, eighteen-month old Josie

King died from medical errors at the Johns Hopkins Hospital

Peter J. Pronovost, MD, PhD is a practicing anesthesiologist and

critical care physician, teacher, researcher, and

international patient safety leader.

Johns Hopkins Medicine Comprehensive Unit-based Safety Program

(CUSP)

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Johns Hopkins Medicine Comprehensive Unit-based Safety Program

(CUSP)CUSP is a 6-step safety programStep 1: Safety Attitude Questionnaire (SAQ) Step 2:Staff education on the Science of SafetyStep 3: 2-item Staff Safety Survey

▪ Please describe how you think the next patient in your unit/clinical area will be harmed?

▪ Please describe what you think can be done to prevent or minimize this harm?

Step 4: Executive Walk RoundsStep 5: a) Learning from our mistakesb) Improve teamwork and communicationStep 6 : Resurvey staff about Safety Culture (annually)

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How we started at Tawam?• January-08 Created the Patient Safety dept.

recruited 4 patient safety officers and a medication safety officer.

• February-08 Leadership training on Patient Safety• April-08 Comprehensive Unit based Safety

Program Roll-Out. • 2008- ICU, NNU, Peds Onc (Pilot Units)• 2011- Medical 1 & 2, Surgical 1& 2, Daycase, PICU• 2012- OBGYN

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CUSP in Ten Units

Challenges faced

• Employees hail from 60 nations• Hierarchies between providers• A culture that isn’t accustomed to

acknowledging medical errors.• Tendency for poor communication and

teamwork that lead to adverse events.• Tawam had a history of, “you made a mistake,

and you’re terminated.”

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CUSP is a leadership driven &

Partnership driven program

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Stakeholders & Team

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“Insanity: doing the same thing over and over again and

expecting different results”Albert Einstein

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“Every system is perfectly designed to achieve the results it gets.”

Donald Berwick, M.D.

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What can we do to improve?

Errors can be prevented by designing systems that make it hard for people to do the wrong thing, and easy for people to do the right thing.

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Critical thinking!!!

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System redesign

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System Design- Forcing Function

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Error Prevention

• “Smart people learn from their own mistakes, wise people learn from other's mistakes.”

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Formula 1 Pit stop

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Formula 1 Pit stop• Takes six to twelve seconds in duration.• Every pit stop is filmed and monitored by

human factor experts• Errors are scored in five levels• Highest score goes to the smallest error,

because people are unaware of it.

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Aviation-Sterile cockpit rule

• Prohibits crew member performance of non-essential duties or activities while the aircraft is involved in taxi, takeoff, landing, and all other flight operations conducted below 10,000 feet, except cruise flight.

• Prohibits the personal use of a personal wireless communications device or laptop computer while a flight crew member is at duty station during all ground operations

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Learning from Defects- Tawam

• Creation of Safety Event Analysis Teams in each CUSP unit.– Identified a team of believers – Team identified defects from Patient Safety Net

(PSN) – Implemented systems changes to reduce the

probability of recurring.– At least one defect was investigated each month.

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System changes due to PSN’s on Narcotic medication error

• Verbal order carried out against policy for Narcotic medication. (Fentanyl Patch)– Analyzed usage of each Narcotic and Controlled

medication (for the previous six months).– Determined Critical/emergency need of each n drug.– List of Narcotic and Controlled medications were

reduced to half.– ICU physicians and nurses informed about the

changes.– Review the usage every 3 months.

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Team members involved being felicitated

In the picture:Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna

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When errors occurThree things happen

• It can cause people to become championsOr • It can cause people to leave the profession

prematurely Or• It can make people go in to a shell and

completely feel withdrawn- Disengaged.

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Medication Error Story-1

Double check for expiration date

not done properly

First Nurse proceeded to

administer the vaccine without

taking the tablet PC to the patient bed

side

Vaccine Injected and asked second Nurse to chart in

Cerner on his behalf

Second Nurse baffled after seeing the expiration date and the missing expiration

date in the label

Error reached the patient but did not cause harm

Expired vaccine arrived from

Pharmacy

SWISS CHEESE MODEL

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Medication Error Story-2

Chemotherapy Written by MD.

Vincristinedoxorubicin

And l_aspargenes

Checked according

To the protocolThen faxed

to pharmacy

Prepared by Pharmacy

MedicationReceived from

Pharmacy ,Checked with

Another Chemotherapy

Competent NurseVCR

DOXOL-Asp

Two medication taken to

patient roomVCR and

DOXOAnd

Emla cream

L-Asp returned to fridge

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Medication Error Story-3

What Happened

•Remicade a non formulary was administered to the patient (order was in paper)

•Premedication of antihistamine, panadol was ordered in CERNER which was not communicated to the nurse

•The patient developed allergic reactions

What Next

•Investigation revealed that there was no set protocols or guidelines

•Break down in communication & information transfer

Action

•Guidelines, protocols and checklist were developed

•No incidents since then

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Implication of the errors

• The staff came open and reported the incidents

• Since CUSP was in place it helped institute a Fair and Just Culture

• Investigation of the incidents, examined the processes and not just people.

• The three nurses have now become advocates of patient safety by sharing their experiences.

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Distribution of Harmful Events by Care Units, 2010

Medical 1

Naima Pharmacy

OR

Paeds Medical

Medical 2

Paeds Oncology

0 20 40 60 80 100 120 140 160 180 200

113

128

139

152

163

183

13

0

29

10

11

3

No. Harmful eventNo. of Reported Event

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Medication Error Story-4(Second Victim)

• A nurse inadvertently administered a chemotherapy drug to a wrong patient. The patient was ok and the error was openly disclosed to the family. It was a clear case of the nurse not adhering to the five seven principle and independently double checking the high alert medication. A case of negligence!!! The nurse had no previous history of such an error was emotionally so distressed that the nurse could no more work in the unit. The patient family members did realize that the error was not intentional and did support the nurse who was devastated due to the incident. Despite the fact that culture of safety program was existence in the unit for over four years, there was no established mechanism to console the nurse. Due to the increased anxiety about the future possibility of errors and loss of confidence in ones own work, tragically the nurse chose to leave the specialty prematurely, the one that the nurse had been working for over fifteen years.

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PSN -Data

2011 20120.0%

20.0%

40.0%

60.0%

80.0%

100.0%

66.7% 63.1%

26.6% 31.6%

6.7% 5.3%

Near Miss Event Reached the Patient with no harm Event Reached the Patient with harm

% R

epor

ted

Med

icati

on R

elat

ed E

vent

s

Medication Error Rate

2011 2012

Medication Error Rate per 10,000 dispensed Items 2.3 1.8

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Celebrating Safety – Viewing workers as heroes

• Best Catch Award 2009• Best Catch Award 2010• Best Catch Award 2011• Best Catch Award 2012

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• To improve reporting and learn from mistakes.• To enhance the culture of safety.• To put focus on processes and at-risk behaviors,

not just on outcomes • To recognize staff for their contribution to

quality and patient safety.• To proactively identify and implement risk

reduction strategies

Objectives

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Patient Safety Net (PSN)PSN- Harm Score 1 & 2 (Near Misses)

Data source

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• Number of people that could be affected.• The likelihood of Occurrence• Severity: The impact(s) of failure• Detectability • Followed with a systemic corrective actions or

plan.

Criteria for selection

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• Preliminary screening/selection was done by the department heads.

• Short list Near Misses were submitted to Senior Leadership Committee for final selection.

Methodology

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Best Catch Award 2009

Synopsis :• Physician placed an order through HIS for patient for paracetamol 1000 mg PO PRN

Q6H for pain/fever was inadvertently documented as 10,000 mg. The pharmacy verified this order as such. Nursing caught the error, and called to have the order modified to paracetamol 1,000 mg PO PRN Q6H for pain/fever.

Ahlem Hussein RN &Sharif Deeb Qandil pharmacist

Prevented high dose of pain medication

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Best Catch Award 2010

Abdulla Odat RN

Synopsis :Chemotherapy IFOSFAMIDE per protocol is for four doses, and it was written for 5 days.

The fifth dose arrived , nurse checked protocol and prevented.

Systemic change :A copy of the protocol in pharmacy and patient chart to double check and prevent errors.

Prevented excess dose of Chemotherapy medication

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Best Catch Award 2011

Synopsis :

Rubella vaccine was ordered. The dose was delivered, clearly in a vial which stated 'single dose'. In other words, the whole vial was a single dose, all of which should be diluted and administered. The pharmacy sent the dose with a special blue label which called for the nurse to pay attention to the specific dose. The nurse called to try to understand what was the actual dose. The pharmacist told her she should only give 1/10th of the vial, once reconstituted. Dr. Jenny who happened to be watching and inspecting the bag with the vaccine thought this was not right. She called the pharmacy again and this time the pharmacist double checked the vaccine changed the recommendation to administer the whole vial. If the nurse had given 1/10 of the dose, the patient would not have been properly immunized. 04/11/2023

Dr. Jennifer CorderConsultant Physician

Prevented improper immunization

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Synopsis :The pharmacist received a medication refill order from a doctor for a pediatric patient and

noted a mismatch between the refill order and the current medication that the patient was taking. She contacted the doctor and the child’s mother, verified the medication and corrected them in the order.

Azhar Talal Pharmacist

Best Catch Award 2011

Prevented wrong refill order of medication

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Best Catch Award 2011

Synopsis

The physician had ordered Metototrexate IT for this patient. In OR the mother of the patient told the nurse that the patient should receive Cytarabin IT, not Metotrexate. The Physician had prescribed the wrong drug.

Iiris PietikainenSenior Charge Nurse/Unit Manager Peds

Oncology

Prevented administration of wrong chemotherapy medication

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Discussion-The End Game

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Healthcare Needs Robust System

• A cooperative effort between government agencies (regulatory authorities), Health Policy makers and industry to lead improvements in safety.

• Healthcare needs an independent body modeled after the National Transportation and Safety Board (NTSB).

http://www.safetyleaders.org/NTSBforHealthcare/home.jsp

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For hospitals to become safer

• Hospital Leaders must say that they will do away with errors.

• Hospital Leaders must realize that an event that occurred in another organization could one day happen in their hospital.

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Positive thing

• UAE-– SEHA one of the largest healthcare systems in the region

has established the PSN reporting tool in all its business entities.

– DHA Implements New Patient Safety System called “Aman” based on a global healthcare safety system called DATIX

• KSA- Is now asking all hospitals, government or private, to use online reporting for any serious medical error.

• Qatar- HMC has introduced real time incident reporting system at its chain of hospitals.

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Resources-websites

• http://www.iom.edu/ • http://www.npsf.org/ • http://www.ihi.org/explore/patientsafety/pages/default.aspx • http://www.hopkinsmedicine.org/armstrong_institute/ • http://www.josieking.org/ • https://www.patientsafetygroup.org/main/index.cfm • http://www.pso.ahrq.gov/ • http://www.patientsafety.gov/ • http://www.safetyleaders.org/• http://www.ismp.org/newsletters/acutecare/articles/20091203.asp • www.emilyjerryfoundation.org

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References• Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington:

National Academy Press; 1999• Sexton J.B., et al.: The Safety Attitudes Questionnaire: Psychometric properties, benchmarking data, and

emerging research. BMC Health Serv Res 6(44):Apr. 3, 2006.• Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual and

Saf 2006 32(2):102-8.• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance Nurse

Leaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.• Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-

Based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf 2010;36(6):252-260.

• Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf 2007;33:467–76

• Rossheim J. To err is human—even for medical workers. Healthcare monster. http://healthcare.monster.ca/8099_en-CA_pf.asp (accessed 21 Jan 2009).

• Wu AW (2000). "Medical error: the second victim. The doctor who makes the mistake needs help too". BMJ 320 (7237): 726–7.

• How many health professionals does a patient see during an average hospital stay? N Whitt, R Harvey, S Child• Ginsburg, L., P. G. Norton, A. Casebeer, and S. Lewis. 2005. ‘‘An Educational Intervention to Enhance Nurse

Leaders’ Perceptions of Patient Safety Culture.’’ Health Services Research 40 (4): 997–1020.

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Culture of Safety is a journey

• It takes as long as 5 years to develop a culture of safety that is felt throughout an organization. (Ginsburg et.al 2005)

• Need Patience, Perseverance, Commitment & Engagement.

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2 question survey

• Please describe how you think the next patient in your unit/clinical area will be harmed.

• Please describe what you think can be done to prevent or minimize this harm.

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Thank YouPatient Safety Top Priority

Patient Safety Everyone's Responsibility

Contacts:ksankara@tawamhospital.ae

050-9211649