Moving Forward 21 st Annual Institute

2. Moving Forward 21st Annual Institute

4. Background - IOM Report • The risk of dying as a result of medical error far surpasses the risk of dying in an airline accident. • Death on Domestic Flights - 1 in 8,000,000 flights

5. Background - IOM Reportcont’d Death in Hospitals from Medical Errors 1 in 343 Admits to 1 in 764 Admits Adverse Events in Hospitals 1 in 27 Admits to 1 in 34 Admits

6. The Patient Safety Learning Lab Top 10 Recommendations for Facility Design • FMEA at each design stage • Standardization of Location • Involve patients/families in design process • Establish a checklist for current/future design • Critical information close to the patient • Noise reduction • Adaptive systems for function in the future • Articulate a set of principles for measurement • Equipment planning Day 1 • Begin mock-ups on Day 1

8. Design Recommendations • Latent Conditions: • Noise reduction • Scalability, adaptability, flexibility • Visibility of patients to staff • Patients involved with their care • Standardization • Automate where possible • Minimize fatigue • Immediate accessibility of information, close to the point of service • Minimize Handoffs • Minimize Patient Movement

9. Design Recommendations, con’t • Active Failures • Operative/Post-Op Complications/Infections • Events Relating to Medication Errors • Deaths of Patients in Restraints • Inpatient Suicides • Transfusion Related Events • Correct Tube-Correct Connector-Correct Hole • Patient Falls • Deaths Related to Surgery at Wrong Site • MRI Hazards

10. Process Recommendations • Matrix Development (post Learning Lab) • FMEA at each stage of design • Patients/Families involved in design process • Equipment planning day 1 • Mock-ups day 1 • Design for the vulnerable patient • Articulate a set of principles for measurement • Establish a checklist for current/future design

11. Creating a Culture of Safety • Shared Values and Beliefs about Safety within the Organization • Always Anticipating Precarious Events • Informed Employees and Medical Staff • Culture of Reporting • Learning Culture • “Just” Culture • Blame-Free Environment Recognizing Human Infallibility • Physician Team Work • Culture of Continuous Improvement • Empowering Families to Participate in Care of Patients • Informed & Activated Patient

12. Our Patient Safe Room