The Science of Improving Patient SafetySean Berenholtz, MD, MHS, FCCMSeptember 4, 2012

Armstrong Institute for Patient Safety and Quality

Conference Number(s):800-779-9891 Participant Code:4757941

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On Boarding Call Schedule

• Program Introduction• Building Your CUSP Team• Science of Safety –September 4, 2012 @2:00pm• Building Your CUSP Team-September 11, 2012 @2:00pm• VAP Evidence- September 18,2012 @ 2:00pm• Daily Goal Review -September 25, 2012 @ 2:00pm

Learning Objectives

• Explain how every system is designed to achieve the results it gets

• Identify and describe the basic principles of safe design

• Apply the principles of safe design to technical as well as teamwork

• Identify how teams make wise decisions when there is diverse and independent input

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Targeted Muscle Re-Innervation(courtesy of Dr. Albert Chi)

1. Nerve Transfers

2. Motor Imagery (3 mo)

3. TMR Prosthetic (6 mo)

4. Sensory functions

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http://home.earthlink.net/~radiologist/tf/050800.htm

The Problem is Large

• In U.S. Healthcare system– 7% of patients suffer a medication error 1

– On average, every patient admitted to an ICU suffers an adverse event 2,3

– 44,000- 98,000 people die each year as the result of medical errors 4

– Nearly 100,000 deaths from healthcare-associated infections 5

– Estimated 30,000 to 62,000 deaths from CLABSIs 6

– Cost of HAIs is $28-33 billion 7

• 8 countries report similar findings to the U.S.

1. Bates DW, Cullen DJ, Laird N, et al., JAMA,19952. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.3. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.4. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.5. Klevens M, Edwards J, Richards C, et al., PHR, 20076. Ending Health Care-Associated Infections, AHRQ, 2009.

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How Can These Errors Happen?

• Every system is perfectly designed to achieve the results that it gets– majority of errors don’t belong to individual

doctors or nurses• People are fallible• Need to view the delivery of healthcare as

a science• Need systems that catch mistakes before

they reach the patient

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Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects….. Their part is that of adding the final garnish to a lethal brew that has been long in the cooking.”

James Reason, Human Error, 1990

System Factors Impact Safety

Case Example

• 65 yo M s/p lung resection for cancer• Admit to ICU; discharged to floor on post-op

day (POD) 1• POD 3 develops hypoxia• Admitted to ICU, intubated• CXR shows extensive left lung collapse• Decision to perform broncoscopy

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System Failure Leading to Error

Bronch cart not stocked

Communication betweenresident and nurse

Fatigue

Patient suffers

Hypoxic arrest

Did not verify equipment availability

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Science of Safety

• Understand principles of safe design

– Standardize, create checklists, learn when things go wrong

• Recognize these principles apply to technical and team work

• Teams make wise decisions when there is diverse and independent input

Health Services Research, 2006; Circulation. 2009;119:330-337

Eliminate Steps

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Create Independent Checks

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Healthcare-Associated Infections (HAI):

A Preventable Epidemic• Focus on 4 HAIs:

– VAP, CLABSI, surgical site infections and catheter associated urinary tract infections

• $5 billion per year excess costs• 1.7 million patients per year

– 1 out of 20 patients• 98,000 deaths per year

– As many deaths as breast cancer and HIV/AIDS– 6th leading cause of preventable deaths

http://oversight.house.gov/story.asp?id=1865

VAP Prevention Guidelines

• CDC Guidelines • MMWR Recomm Rep. 2004;53:1-36

• American Thoracic Society/Infectious Diseases Society of America

• AJRCCM 2005;171(4):388-416.

• Canadian VAP Prevention Guidelines • J Crit Care 2008;23(1):138-147.

• Society for Healthcare Epid of America/Infectious Diseases Society of America

• ICHE 2008;29:S31-S40. 16

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Improving Care for Ventilated Patients

• Semirecumbant positioning

• Peptic ulcer disease and DVT prophylaxis

• Appropriate sedation

• Daily assessment of readiness to extubate

• Minimize contamination of equipment

Improving Care for Ventilated Patients

• Educate staff

• Decrease complexity / create redundancy: – Daily goals checklist

• Other independent redundancies– Nursing and families– Are patients receiving the prevention they

should?

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Sample Daily Goals

• What needs to be done for the patient to be discharged?

• What is the patients greatest safety risk?

• What can we do to reduce the risk?

• Can any tubes, lines, or drains be removed?

J Crit Care. 2003;18(2):71-75

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Michigan Keystone ICU – Results

• 124 of 127 ICUs submitted VAP data– 12 ICUs started after funding ended

• 112 ICUs, 72 hospitals included in analysis• 3228 ICU months and 550,800 vent days• 10% quarters without complete data

– 4% missing data; 6% stopped submitting data• Sensitivity analysis yielded similar results• Results reported through 28-30 months post-

implementation

Michigan Keystone ICU – Bundle Adherence

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Michigan Keystone ICU

Infect Control Hosp Epidemiol. 2011;32(4): 305-314.

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Michigan Keystone ICU

Principles of Safe Design Apply to Technical and Teamwork

Communication breakdowns are frequently the root cause of…

undesirable outcomes

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Teams Make Wise Decisions When There is Diverse and Independent Input

• Wisdom of Crowds

• Redundancy is two sets of eyes trained differently looking at same picture

• Structured communication tools linked to improved patient and economic outcomes

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Structured Communication

• Briefings and Debriefings

– Reductions in complications;mortality 1,2

• Daily goals

– 654 new ICU admissions; $7 million additional revenue 3

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1 N Engl J Med 2009;360:491-9.2 JAMA 2010;304(15):1693-1700.3 J Crit Care 2002;18(2):71-5.

Summary

• Safety is a property of systems• Standardize, create checklists, learn when

things go wrong• We need lenses to see the system

• Recognize these principles apply to technical and team work

• Teams make wise decisions when there is diverse and independent input

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• Have all staff, unit leadership and executive leaders view the Science of Improving Patient Safety video

• Put together a roster of who needs to view the Science of Safety video, establish a timeline for completion and track progress

Action Items

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Finalize enrollment

• Complete and submit the commitment/enrollment form

• Questions or comments:

– Karol G. Wicker, MHSSenior Director, Quality Policy & Advocacy

Maryland Hospital Association

kwicker@mhaonline.org

– Mary Catanzaro RN BSMT CIC Project Manager HAIs

Hospital and Healthsystem Association of Pennsylvania

mcatanzaro@haponline.org

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References

Slide 6

1. Bates DW, Cullen DJ, Laird N, Peterson LA, Small SD, Servi D, Laffel G, Sweitzer BJ, Shea BF, Hallisey R, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995 Jul 5;274(1):29-34.

2. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky M, Sprung CL, Pizov R, Cotev S. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995 Feb;23(2):294-300.

3. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Vargish T, Siegler M. An alternative strategy for studying adverse events in medical care. Lancet. 1997 Feb 1;349(9048):309-13.

4. Kohn LT, Corrigan JM, Donaldson MS. Committee on Quality of Health Care in America, Institute of Medicine. The National Academies Press. 2000.