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Do No Harm: Culture, Technology, Teamwork and Design Change. Nancy G. Pratt RN, MSN, SVP, Clinical Effectiveness Sharp HealthCare February 5, 2007. Sharp’s Strategic Plan for Patient Safety. Develop a Culture of Safety Use Technology to Improve Safety

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do no harm culture technology teamwork and design change

Do No Harm: Culture, Technology, Teamwork and Design Change

Nancy G. Pratt RN, MSN,

SVP, Clinical Effectiveness

Sharp HealthCare

February 5, 2007

sharp s strategic plan for patient safety
Sharp’s Strategic Plan for Patient Safety

Develop a Culture of Safety

Use Technology to Improve Safety

Address Human Factors: Teamwork and Communication

Redesign the Processes

Culture

Human

Factors

Reduce Harm by 50% over 5 years

Design

Technology

strategic priorities patient safety
Strategic Priorities: Patient Safety
  • Implement a Culture of Safety
    • Anonymous reporting
    • Collaboration: San Diego Patient Safety Consortium
    • Adverse Events Program
  • Teamwork and Communication
    • Team Resource Management
    • Standard Work Processes
  • Use Technology to Improve Safety
    • Bar Coding
    • Electronic Safety Triggers
    • Electronic variance reporting
    • Smart Pumps – IV, PCA, Syringe
  • Redesign for Safety
    • Human Factors Engineering
    • Design for Six Sigma
    • Product, supply, process review
    • JCAHO National Patient Safety Goals
slide5

Alternate Actual Process

Physician gives order

RN can’t get med out of Pyxis

RN writes

order & faxes

to Pharmacy

RN faxes & calls pharmacy again!

Onset of Complaints!

Fax doesn’t go through!

Pharmacist not available

Drug not available

RN Calls pharmacy, faxes order again!! Fills out standard pharmacy complaint – QVR!

Pharmacy Tech delivers med someplace in SICU

Pharmacy informs RN med has been there for 2 hours

pharmacy order cycle time
Pharmacy Order Cycle Time

Pharmacy Staffing Not Matched to Medication Order Volume

# Medication

Orders

Pharmacy

Staffing

Time of Day

pharmacy order cycle time7
Pharmacy Order Cycle Time

Baseline

After Initial Improves

After Pharmacy IT System Changed

After Fax Server Installed

med admin flow map ideal average time 7 mins

Medication Safety Project: Decrease Interruptions

Med Admin Flow Map(Ideal)Average time~ 7 mins

RN preps med

RN Prompted to give med

RN identifies patient

RN interprets MAR (5Rs)

RN explains med to pt

RN performs preadministration assessment / checks allergies

RN prepares to admin med

(final 5Rs)

RN washes hands

RN evals effects of med

RN gives med

RN procures med/IV & supplies (5Rs)

RN documents med

RN washes hands

med admin flow map more real average time 20 mins
Med Admin Flow Map(More real)Average time ~ 20 mins

RN preps med

RN Prompted to give med

Wait in line

RN identifies patient

RN interprets MAR (5Rs)

Phone call

Phone call

Order is questionable

RN explains med to pt

RN performs preadministration assessment / checks allergies

Need to clarify

Unexpected nsg task

RN prepares to admin med

(final 5Rs)

Call MD;

Wait;

Get clarification

RN washes hands

Locate Missing supply

RN evals effects of med

Unexpected nsg task

RN gives med

Phone call

RN procures med/IV & supplies (5Rs)

Can’t find med; look in 4 places; call pharm

RN documents med

RN washes hands

slide11

CR

  • Waited in line to get meds @ 9:00
  • One med grayed out – not here, one gray ed at – in refrigerator
  • Search refrigerator
  • Went to P #1, found 1 med – MVI still missing, tapped drawer to get cubie to open
  • Two meds left to find – may be in room. Crushed meds in paper cups
  • Piston syringe in room – No date – went to supply room to get another
  • Found MVI but NO med cups - ? Refrigerator MVI
  • Searched room for fiber or med cup – on bedside table – no way to administer
  • Back to med room
  • Back to room
  • Mixed meds in cup in admin – DONE 0920
  • Medication Delivery Total Time – 13 minutes
what does the literature tell us top high risk situations causing sentinel events
What Does the Literature Tell Us? Top High Risk Situations Causing Sentinel Events
  • Distractions before or during administration of meds or treatment
  • High alert drugs used without double-checks
  • Multi-tasking
  • Care provided under a human-error-prone situation (dark, noisy, shift change) without appropriate compensatory actions

Reason, JT. Understanding adverse events: human factors. In Vincent

CA (ed) Clinical Risk Management. London: BMJ Pub; 1995

medication safety action plan
Medication Safety Action Plan

Create a standard environment for medication room design and processes

5’S’ Principles

- Sort

- Shine

- Simplify

- Standardize

- Sustain

Minimize interruptions and distractions during medication administration

  • Respect med admin as a critical activity
  • Divert and discourage unnecessary calls
  • Encourage all disciplines to limit interruptions Create Scripting examples for nurses
  • Evaluate workload demands during high volume med admin times
medication safety action plan14
Medication Safety Action Plan

Develop a standard guideline for

medication preparation and administration

  • Avoid conversations in med room
  • Discourage interruptions/distractions
  • Verify using 7 “Rights”
  • Prepare and administer to 1 pt at a time
  • Independent double check insulin, heparin, warfarin
  • Use MAR or Pyxis label to verify 7 ‘R’s
  • Document
number of unnecessary interruptions during med pass pre and post
Number of ‘Unnecessary’ Interruptions During Med Pass: Pre and Post*

p=0.000

*No statistical difference in number or route of meds given

sgh 5e pilot med pass time pre and post
SGH 5E Pilot Med Pass TimePre and Post*

p=0.037

*No statistical difference in number or route of meds given

emergency department rme
Emergency Department: RME
  • ED patients expect quick service and to be seen by an ED doctor, regardless of diagnosis
  • 40% of ED pts are non-emergent
  • Rapid Medical Exam (RME) designed to promptly and appropriately “treat & release”
  • Issues: long waits, space, multiple entry points, flow, communication…
growth of ed visits
Growth of ED Visits
  • 1992: 12 beds = 16,640 visits. 2006: 22 bed =45,456 visits.
  • 173% increase in visits since current ED was opened in 1992.
  • 83% increase in beds over same period.
bottlenecks in the ed
Bottlenecks in the ED

PHLEBOTOMY

TRIAGE

LOBBY

RME

Lack of open ED beds creates bottlenecks. Many patients wait in front lobby area.

rme project goals
RME Project Goals
  • Take vitals of all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%)
  • “Arrival noticed quickly” satisfaction = 85th percentile (baseline 18% Dec-06)
  • Establish RME triage standard to set stage for RME cycle time project
ed rme outcomes
ED RME Outcomes
  • Goal: Vitals on all ESI level 2-3 patients in lobby every 90 min 90% of time (baseline: 0%). Improvements:
    • Guard providing safe environment
    • LVN assigned to check vitals
    • Designed EmStat report to monitor lobby patients
ed rme outcomes26
ED RME Outcomes

Goal: 80th %tile

slide27

Reconciliation of medications across the continuum of care

  • RoMACC at Grossmont Hospital
  • Project Description / Vision:
    • Implement a ‘Lean’ RoMACC process that demonstrates value, not just in terms of patient safety but in efficiency for practitioners.

Start Date: September 2006Go Live: December 5thEnd Date: March 2007

Participants:

Champion/Green Belt:

Julie McCoy

Jackie Parson

Black Belt:

Kurt Hanft

Sponsor:

Michele Tarbet

MD Partner/ Process Owner:

Dr. Margaret Elizondo

Next Sustain and Improve!

slide28

Reconciliation of medications across the continuum of care

  • RoMACC Measurement Method:
  • Discharge:

Physician

writes the Discharge Orders and Addresses the Discharge Reconciliation.

Unit clerk

verifies the reconciliation has been addressed and enters a discharge order

Process Measure

slide29

Reconciliation of medications across the continuum of care

  • RoMACC and Discharge Measurement:
  • % RoMACC Complete
  • Carecast Discharge Order Entry Compliance
  • Number Of Discharges
  • Time to Discharge a Patient
  • Average Time of Day a Patient Leaves.

Combined projects

slide30

Reconciliation of medications across the continuum of care

  • RoMACC at Grossmont Hospital

75% System Goal

Continuous Improvement – Above System Goal of 75%

examples of patient safety improvements
Examples of Patient Safety Improvements:
  • Use Technology to Improve Safety
    • Bar Coding
    • Electronic Safety Triggers
    • Electronic variance reporting
    • Smart Pumps – IV, PCA, Syringe

Innovation with our partners: Cerner

  • Bar Code Implementation (Roche)
    • Real Time Event Triggers “On Watch” (Clinicomp)
    • Electronic Quality Variance Reporting (Peminic)
    • Wireless Smart Pumps CQI data (Cardinal)
    • Standardization of IV infusion concentrations (SDPSC)
    • Enteral Tubing connections (Viasys, FDA, AHA)
slide34

Bag/Bottle of Enteral Feeding

Feeding Bag

Tubing Set

l

Enteral Feeding Tube

Tubing Misconnections

patient safety strategy
Patient Safety Strategy
  • Redesign for Safety
    • Human Factors Engineering
    • Design for Six Sigma
    • Product, supply, process review
    • JCAHO National Patient Safety Goals
patient safety actions
Patient Safety Actions
  • Products:
    • Insulin Syringe
    • Dopamine Drip Bottle versus Bag
    • Enteral Feeding Bag versus Bottle
    • Heparin Flush versus Therapeutic infusion
    • Anesthesia Tray for Epidural
    • Cat Scan Contrast Injectors
    • IV PICC Line Cap Leaking (CLC 2000)
    • Insulin and Heparin Infusions – standardized
    • Endotracheal Tube with Sub-glotic suction
san diego s health care leader

Magnet Status

Sharp Grossmont

Excellence in Patient Safety and Health Care Quality, 2006

100 Most Wired Hospitals, 1999-2006

IDG's Computerworld, 2006

Best Integrated Health-Care Network in California, 2007

Best place to work, 2004

Torch Award for Marketplace Ethics

San Diego’s Health Care Leader

Malcolm Baldrige

National Site Visit, 2006

Gold Eureka Award, 2006

Silver Eureka Award, 2005

Bronze Eureka Award, 2004