Perinatal Patient Safety Concepts & Reality

1. Perinatal Patient SafetyConcepts & Reality Cheryl Raab, BSN, RNC-OB, C-EFM Perinatal Patient Safety Nurse Yale - New Haven Health System

2. Disclosure Statement • I have no relevant financial relationships to disclose. • There will be no discussion of unapproved or off-label, experimental or investigational use of products, drugs or devices.

3. Objectives • Discuss the concern for patient safety in history • Examine the current nature of medical error • Review concepts of safety science and their application to perinatal care

4. What is Patient Safety? • “…freedom from accidental or preventable injuries produced by medical care. Thus, practices or interventions that improve patient safety are those that reduce the occurrence of preventable adverse events” AHRQ PSNet Patient Safety Network Glossary

5. Patient Safety in History

6. 4th Century • I will prescribe regimen for the good of my patients according to my ability and by judgment and never do harm to anyone. Hippocratic oath • As to disease, make a habit of two things – to help, or at least to do no harm Epidemics (Book I, Chapter XI)

7. 18th Century • Commissioned by Louis XV to teach midwifery to reduce infant mortality Angélique du Coudray

8. 19th Century • ‘Savior of Mothers’ • Discovered incidence of puerperal fever could be drastically cut by use of hand washing IgnazSemmelweis

9. 19th Century “It may seem a strange principle to enunciate as a first requirement in a hospital that it should do the sick no harm” Florence Nightingale, Notes on Hospitals

10. 21st Century • United Kingdom, Canada, Denmark, New Zealand, Australia – similar reports • World Heath Organization concluded that serious, preventable adverse events occur during 1 out of every 10 patient hospitalizations in developed countries Donaldson LJ. Med J Aust. May 15, 2006; 184(10 Suppl):S69-72

11. What is the Challenge?

12. Sir Cyril Chantler • Medicine used to be simple, ineffective and relatively safe. • Now it is complex, effective and potentially dangerous. Chantler, C. (1999). The Lancet, 353(9159), 1178-1181.

13. How big is the problem? • 44,000 - 98,000 Americans die in hospitals each year as a result of preventable medical error Kohn LT. (1999). To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academy Press • 70% of obstetrical malpractice claims involved substandard care and preventable injuries Clark, S. L., Belfort, M. A., Dildy, G. A., & Meyers, J. A. (2008). Obstetrics & Gynecology, 112(6), 1279-1283.

14. Institute of Medicine • 44,000 - 98,000 Americans die in hospitals each year as a result of preventable medical error

15. Error • A deviation from accuracy or correctness as in an action; a mistake • May include problems in practice, products, procedures, and systems. • Synonyms: blunder, boo-boo, slip, slip-up, inaccuracy, oversight, fault, miscalculation

16. Institute of Medicine • 44,000 - 98,000 Americans die in hospitals each year as a result of preventable medical error

17. Medical error • An injury caused by medical management rather than the underlying disease. • The failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.

18. Institute of Medicine • 44,000 - 98,000 Americans die in hospitals each year as a result of preventable medical error

19. Preventable medical error • An unintended outcome due to medical care that results from practice, products, procedures or system breakdowns • Retained foreign object during surgery • Wrong medication ordered and administered • Wrong procedure performed • Wrong sided surgery • Hospital acquired infections • Failure to diagnose correctly • Falls • Pressure ulcers • Etc, etc, etc…….

20. What is the nature of Error?

21. Human Factors • Human factors - application of what we know about human capabilities and limitations to the design of equipment and devices in order to enable more productive, safe, and effective use

22. Human Factors History • World War II • Planes crashing • Bombs missing targets • Friendly ships sunk • High Reliability Industries Atomic Energy Airline Industry

23. Human Factors in Medicine • 1970s • Concern for anesthesia gas machines • 1990s • IOM concern for medical errors

24. What is the underlying nature of medical error?

25. Causes of medical error Active Condition Latent Condition Obvious errors ‘Sharp end’ Happen at interface between a person (healthcare provider) & an aspect of care (patient, machine) Failure to check pt. ID Circumcising the wrong infant Giving wrong blood/medication to pt. Ignoring the alarm on the EFM monitor RN programming the infusion pump improperly Conditions that are present but have not been consciously realized Accidents waiting to happen ‘Blunt end’

26. Latent conditions • Staffing – chronic understaffing; staff mix • Equipment – missing; old, jerry-rigged • IT – lack of needed interfaces; EHR issues • Policy & Procedure – lack of policies • Teamwork Factors – hand-offs; communication • Training - no competency for the task • Work environment – distractions; multitasking; rushing • Management /Organization – finance over pt. safety • Human – fatigue; personal illness; habit; hurry

27. Swiss cheese model • Individual behavior alone is not enough to account for most adverse events. Pt.’s allergies not obtained on adm. Nurse administers medication to which pt. is allergic Contra-indicated medication ordered Medication missing in Pyxis; Nurse borrows from another pt. Anaphylactic reaction → arrest

28. Culture of Safety • It’s about reducing patient harm • Error cannot be eliminated • Even highly skilled professionals will err when confronted with a sufficiently stressful set of circumstances “…accept the notion that error is an inevitable accompaniment of the human condition, even among conscientious professionals with high standards.” Lucien Leape, 1994

29. Views on human errors

30. Human error as ‘Cause’ • Person approach – to explain failure → seek failure • Focus on the unsafe act • Moral weakness / Aberrant mental processes • Forgetful • Careless • Negligent • Inattentive • Limits ability to learn from error • Decreases self-reporting • Increases likelihood of re-occurrence • Preventive strategies are based on blame & shame • ‘Old’ M & M process • Litigious environment • “Try harder”

31. Human error as ‘Symptom’ • System approach – to explain failure →look at the systems • Humans are fallible • Error cannot be eliminated; Error is the consequence of the system • Increases self-reporting • With appropriate f/u, decreases likelihood of re-occurrence • Preventive strategies are based on changing the conditions under which humans work: learning from safety events • See the event through the eyes of the healthcare team • What were they thinking and why? • Examines ‘How’ & ‘Why’ the defenses failed

32. Human error themes • Slips, Lapses & Mistakes • Normalization of Deviance • Miscommunication • Loss of Situational Awareness

33. Slips, Lapses and Mistakes

34. Case Study • 28 y.o. (R.N.) G2 P1001 admitted at 39+3 wks. in labor • c/s called for failure to dilate • Uncomplicated procedure on Friday • Saturday – c/o “something’s not right”; increased abdominal discomfort & distention; pt. requested x-ray • Sunday – distention increased; increased abdominal pain; nausea; abdominal flat plate done @23:30 & read by Ob/Gyn resident • Monday – no change • Tuesday – official read of x-ray done → radiopqueobjectLLQ; returned to OR; lap sponge removed

35. Slips, Lapses & Mistakes • Adequate plan → execution failure • Slips, Trips – • Relate to observable actions • Attentional failures • Lapses – • Relate to internal events • Failures of memory • Inadequate plan for intended goal • Mistakes – • Failure of intention, judgment, problem solving • Rule based vs Knowledge based • Rule based: misapplication/non-application of a good rule or application of a bad rule • Knowledge based: unfamiliar situation needing critical thinking Routine task in familiar surrounding

36. StrategiesSlips, Lapses & Mistakes • Teamwork Training • Anonymous event reporting systems • Track & trend situations, tasks and organizational factors • Limited remedial actions

37. Normalization of Deviance

38. Case Study “When I was a third-year medical student, I was observing what turned into a very difficult surgery. About 2 hours into it and after experiencing a series of frustrations, the surgeon inadvertently touched the tip of the instrument he was using to his plastic face mask. Instead of his requesting or being offered a sterile replacement, he just froze for a few seconds while everyone else in the operating room stared at him. The surgeon then continued operating. Five minutes later he did it again and still no one did anything. I was very puzzled, but when I asked one of the nurses about it after the operation, she said, “Oh, no big deal. We’ll just load the patient with antibiotics and he’ll do fine.” And, in fact, that is what happened; the patient recovered nicely.” Banja, J. (2010). Business Horizons, 53(2)

39. Normalization of Deviance • Error results from a long incubated problem • Identified in analysis of Challenger (deficient O rings) & Columbia (shedding debris) disasters • Every work group begins its work with agreed upon standards (new RN / intern) → over time those standards will degrade • How does it happen? • Team “gets away with it” • Rules are “stupid” • Lack of knowledge of policy → taughtthe deviance in orientation • Work arounds “for the good of the patient” • Rules don’t apply to me

40. StrategiesNormalization of Deviance • Fundamental commitment to patient safety • Modeled by leadership • ‘Rounding to Influence’ • Preoccupation with failure • Pay attention to the weak signals • Support the difficult conversations • Reward those who speak up • Great Catch Award

41. Miscommunication

42. Case Study • Jane Smith – admitted to Med/Surg floor • Ordered for a routine chest x-ray • Nurse instructed transporter that Ms. Smith had a thoracic spine fx. and should remain flat with no log rolling for transfer to x-ray table • X-ray staff instructed transporter to leave Ms. Smith in the holding area and to transport another pt. back to the unit • Radiology staff took M. Smith into room for x-ray and sat her up to maximize quality of study • Another transporter returned Ms. Smith to her room where she was found sitting upright in bed • Neurologic exam revealed that Ms. Smith could no longer move her legs

43. Miscommunication • Most frequently identified root cause of sentinel events • Handoffs provide opportunity for error

44. StrategiesMiscommunication • Structured communication • CUS • SBAR • Administrative data – name, MRN, unit New clinical information Tasks to be performed Illness severity Contingency plans • Limit interruptions • Close loop communication • Use ‘repeat back’ and clarifying questions • Keep the communication patient centered • Briefings / Debriefings

45. Loss of Situational Awareness

46. Case Study • Pt. admitted at 4P following SROM • G2 P1001; prior c/s – strongly desires TOLAC • EFM tracing Category I; cervical Foley placed • 16 hrs. later cervical Foley out; pitocinaugmentation begun @ 2 milliunits • EFM – Category I • 8 hrs. later: prolonged decelerations; pitocin discontinued; continues to labor; EFM Category II • 8 hrs. later: fully dilated; pushing begun; minimal variability • 15 mins. later: EFM Category II, recurrent variable & late decelerations, minimal variability; descent noted • 45 min. later: vacuum assisted operative vaginal delivery – Apgar 0 / 4 / 6; cord arterial gases 6.88 / -22 • Baby dx’d with unspecified hypoxic ischemic encephalopathy

48. Loss of Situational Awareness • Ability to identify, process, and comprehend the critical elements of information about what is happening to the patient & team; knowing what is going on around you. • Clues to loss: • Confusion or gut feeling • Use of improper procedures • Failure to meet planned targets • Unresolved discrepancies • Ambiguity • Fixation / Preoccupation

49. StrategiesLoss of Situational Awareness • Team Training • Briefings / Huddles • Cross monitoring • Recognize, speak up, act • Chain of Command (Consultation) • “Stop the line”

50. Chain of Command