Meeting the Critical Challenge to Ensure Patient Safety & Quality

1. Meeting the Critical Challenge to Ensure Patient Safety & Quality Glenda M. Payne, MS, RN, CNN Director of Clinical Services Nephrology Clinical Solutions

2. Objectives 1. Describe common risks to the safety of dialysis patients 2. Examine ways to use quality improvement techniques to decrease risks and improve the quality of care delivered 3. Discuss initial steps to implement a facility based program to improve quality and safety

3. Risks to Patient Safety: Medical Errors • Medical errors in the US result in an estimated 44,000 to 98,000 unnecessary deaths >1,000,000 instances of harm each year. • A 13.5% level of harm was identified within the US Medicare population Institute of Healthcare Improvement (IHI)

4. Cost of Medical Errors • According to the Institute of Medicine, medical errors add $17 to $29 billion per year to the costs of healthcare in the US.

5. Most Common Causes of Patient Injuries • Wrong site surgery • Medication errors • Healthcare acquired infections • Falls • Readmissions • Diagnostic error National Patient Safety Foundation (NPSF)

6. Most Common Patient Injuries: Potential in ESRD • Wrong site surgery • Medication errors • Healthcare acquired infections • Falls • Readmissions • Diagnostic error National Patient Safety Foundation (NPSF)

7. Preventing Medication Errors in ESRD • Refocus routine “home med” reviews: make medication reconciliation a priority • Medication changes happen: • With physician office visits • With “secondary” illness • With hospitalizations • With ER visits

8. Medication Errors in ESRD Protocol driven medications: risk for errors? • Standard routine for changes? • Is the “driver” individualized care? Other potential “medication” errors: • Heparin • Saline • Water/Dialysate • Dialysis prescription

9. Healthcare Acquired Infections in ESRD • To lessen this risk: • Vaccinations • Infection control • Active monitoring program • Patient education • Staff education • Practice audits

10. Reducing the Risk for Falls • Risk assessment • On admission • With each reassessment • With any change in patient cognition or mobility • Implement measures to protect patients at higher risk • Remove environmental hazards

11. Reduce the Risk of Hospital Readmissions • Reassess after hospital discharge • Revise the patient plan of care (POC) as needed • Medication reconciliation • Address changes in function, cognition, mobility • Involve patient support system • It takes a TEAM…

12. Diagnostic Errors in Dialysis • Think fluid management…

13. How Do You Make Your Facility Safer? • Staff orientation • Staff training • Competency testing • Continuing education • Audits of practice • Patient education • Routine PE inspection

14. Other Ways to Prevent Patient Injury Build in Safety: • Product ordering/ receipt of supplies • Systems design “Human factors” design: the study of all aspects of the way humans relate to the world around them, with the aim of improving performance and safety Wikipedia

15. Human Factors Design • Do you store heparin near lidocaine? • Do you store different strengths of heparin near one another? • Do you fill jugs with different acid concentrations—while all the jugs are on the same cart? • How can you design your work space so that errors are less likely to occur?

16. How To Build A culture of Safety IN Your Facility

17. Quality Improvement Constant Process Plan Act Patient Safety Do Study

18. Involve the Whole Team In QAPI Use key staff members to: • Identify safety issues • Formulate solutions • Test those solutions • Implement the best solution • Measure outcomes in order to improve patient safety

19. Too Many Of Us Never Get Above Data…

20. Effective QAPI • Cannot improve what you do not measure • Takes at least three “points” to see a trend • Data is meaningless without analysis • If you don’t document it, you didn’t do it (and you won’t remember it next month!) • Make a plan, implement the plan, evaluate effectiveness, repeat

21. Root Cause Analysis • Use an interdisciplinary team • Include the most expert frontline staff • Include those most familiar with the situation • Use an impartial process • Goal: identify changes that need to be made to systems

22. How How How Focus On The Why & How, Not The Who Root Cause Why Why Why Why

23. Prevention Not Punishment The goal should be to find out: • What happened • Why did it happen • What to do to prevent it from happening again

24. Target Systems, Not People • “Name and blame” culture allows underlying systems-based problems to be ignored and not addressed • In “no blame” cultures, near misses are reported and learned from: leading to continuous quality improvement and safer environments for patients

25. latent errors Patient Exposure to ChlorineSwiss Cheese Model steps PatientsHarmed Staff training Float Charge Nurse Labeling of testing sites Change in testing method Pressure to get patients on

26. Can Never Eliminate All Errors • Critical to design systems that are “fault tolerant”, so that when an individual error occurs, it does not result in harm to a patient VA National Center for Patient Safety

27. Patient Safety Program Repeat Assess Plan Implement • Develop facility PE monitoring tool • Develop staff ed • Develop med error reduction plan • Develop IC guidance • Develop patient education • Inspect facility for hazards • Evaluate staff competency • Determine med error rate • Determine infection rate • Evaluate patient engagement • Routinely monitor PE • Educate staff • Implement med error reduction plan • Implement IC plan • Educate patients

28. But I’m Just One Person… Most errors are the result of failures related to: • Assumptions • Presumptions • Communication On your own, you can improve each of these areas!

29. Assumptions and Presumptions • “Assume” that every medication you are responsible for is potentially lethal: build in multiple check points to be sure the med is “right” for this patient • Presumptions: routinely question presumptions—don’t presume someone has tested the water…or that the patient coming back from hospital has the same target weight as before

30. Communication: The Hardest Thing • “Basic rule in human communication: if it can be misread, misunderstood, misinterpreted, misqualified, or just plain missed, it will be.” Nance. 2008. Why Hospitals Should Fly

31. Learn To CUS • Concerned/ Uncomfortable/ Safety • “I’m concerned about Ms. Jones’ dry weight. She just returned from the hospital and her records say she was coming off at 63 kg. there. I’m uncomfortable trying to take her much lower than 63 kg, and am not sure it is safe to try to take her weight down to 59 kg. now.

32. Thanks for the Work You Do! gpayneful@aol.com