Taking Care of Patients Safely Pitt County Memorial Hospital

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Let’s not learn patient safety by accident…

Willie King, age 51 with a history of diabetes, consented to a have a below knee amputation on his right foot. Surgeons amputated is left foot in error.

Prior to surgery, Willie joked with the medical staff, “You know which one it is, don’t you? I don’t want to wake up and find the wrong one gone.”

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Let’s not learn patient safety by accident…

Joan Faulkner was badly burned in a hospital in North Carolina when a cauterizing tool ignited the oxygen that she was receiving during a routine surgical procedure. Her top lip was burned off, her face, neck and chest suffered 2nd and 3rd degree burns.

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The Institute of Medicine estimates 44,000 to 98,000 deaths occur each year due to medical errors

An additional 100,000 deaths occur each year from hospital-acquired infections, half of which were preventable

Probability of a patient dying in a hospital due to an human error is 1 in 300.

The Costs of Mistakes

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These types of errors can happen

at any hospital!

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Learning About Human Error

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Why Do Events Happen?

Sometimes multiple errors line up to allow

a significant event or injury

to occur

Sometimes an error occurs, but an event or injury is prevented by an internal system of checks

Significantevents orinjuries

From Managing the Risks of Organizational Accidents, James Reason

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Human Error Classification

There are 3 major categories of errors

Skill-based errors Rule-based errors Knowledge-based errors

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Human Error Classification

Skill-Based Errors

Errors made when performing acts or tasks while utilizing skills on “auto-pilot”

Skill-based errors most often occur during lapses in attention (e.g. when we’re pressed for time, or when the action is so routine we don’t pay attention).

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Human Error Classification

Rule-Based Errors

Errors made when performing acts or tasks that require application of rules accumulated through experience and training

Types of Rule-Based Errors Wrong Rule Misapplication of Correct Rule Non-Compliance with Rule

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Human Error Classification

Knowledge-Based Errors

Errors made when performing acts related to new or unfamiliar situations that require problem solving or when a rule does not exist or is unknown to the performer

Types of Knowledge-Based Errors Decision-making Problem solving

Behavior Based Expectations & Tools to Assist in the Reduction of Errors

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Behaviors for Physicians

1. Pay Attention to Detail Self-check using STAR

2. Communicate Clearly Repeat-backClarifying questionsPhonetic/numeric clarificationSBAR

3. Handoff Effectively SBAR

4. Support Each Other Speak-Up/Listen using AAAEncourage questions

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BBE #1: Pay Attention to Detail

Focus attention to always think before we act.

Why should we do this? To avoid unintended slips or lapses To reduce the chance that we’ll make an error when we’re

under time pressure or stress

When should we do this? Before we act, speak, and document

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Error Prevention Tool

Self Checking Using STAR

Stop:

Think:

Act:

Review:

Pause for 1 to 2 seconds to focus on what you’re about to do

Think about what you’re about to do – focus on the action

Concentrate and perform the task

Check to see if the task was done right

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BBE #2: Communicate Clearly

Communicate correct information in a timely and appropriate manner.

Why should we do this? To ensure that we hear things correctly and that we

understand things correctly To prevent avoid wrong assumptions and

misunderstandings that could cause us to make wrong decisions

When should we do this?Whenever we communicate information – either in person or over the phone – that could affect the care and safety of a resident or an employee

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Error Prevention Tool

3-Way Repeat Backs

When information is transferred...

1

2

3

Sender initiates communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear and concise format.

Receiver acknowledges receipt by a repeat-back of the order, request, or information.

Sender acknowledges the accuracy of the repeat-back by saying, That’s correct! If not correct, Sender repeats the communication.

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Error Prevention Tool

Clarifying Questions

Ask 1 to 2 clarifying questionsWhen in high risk situationsWhen information is incompleteWhen information is ambiguous

WHY: To reduce the probability of making a wrong assumption. Asking clarifying questions reduces the risk by 2 1/2 times!!

HOW: Phrase your clarifying questions in a positive way and in a manner that will get an answer that improves your understanding of the information

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Error Prevention Tool

Phonetic Clarifications

letter followed by a word that begins with the letter. For example:For sound alike words, say the letter followed by a

word that begins with the letter. For example:

A AlphaB BravoC CharlieD DeltaE EchoF FoxtrotG GolfH HotelI India

S SierraT TangoU UniformV VictorW WhiskeyX X-RayY YankeeZ Zulu

J JulietK KiloL LimaM MikeN

NovemberO OscarP PapaQ QuebecR Romeo

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Error Prevention Tool Numeric Clarifications

For sound alike numbers, say the number and then speak each digit of the number. For example:

15…that’s one-five

50…that’s five-zero

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BBE #3: Handoff Effectively

Handoff patients or tasks by giving appropriate information and ensuring understanding and ownership.

Why do we have this behavior? To ensure that complete and accurate information about the patient,

project, or task is communicated when responsibility transfers from one individual to another

When should we practice this behavior? When turning responsibility for a patient, project, or task to another

individual

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Error Prevention Tool

SBAR for an Effective Handoff

When transitioning care to another physician, or when requesting a

consult on a patient, use the SBAR technique to organize your

communication

Situation: Describe the situation, patient or question

Background: Highlight the important information, precautions, issues

Assessment: Outline your read of the situation, problems and precautions

Recommendation: State your recommendation, request or plan

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BBE #4: Support Each Other

Speak Up for Safety by using the Triple A techniqueAsk (Do you think we should order a CXR?)Advocate (I think we need to order a CXR.)Assert (I’m concerned that we may miss something if we

don’t get a CXR.)

TipsUse the lightest touch possible…When asserting, use the safe word: “concern”If not successful and you’re still worried, then use chain of

command

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Encourage Questions

Top 3 Statements to Encourage Critical Thinking1

1. “What do you think?”2. “That is an interesting question”3. “Let’s explore this”

Asking a question is an emotional security issue. Foster a culture of critical thinking by encouraging questions. Invite questions, and use positive reinforcement when questions are asked.

1 Rubenfeld, “Critical Thinking Tactics for Nursing”

Encourage questions by inviting questions and positively reinforcing questions when asked.