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Learning from a Defect: Team Exercise Jill Marsteller, PhD, MPP. Workshop Objectives. Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety Program. Describe the process used to identify and eliminate system defects.

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Learning from a Defect:Team ExerciseJill Marsteller, PhD, MPP

© 2007 JHU Quality and Safety Research Group 1


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Workshop Objectives

  • Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety Program.

  • Describe the process used to identify and eliminate system defects.

  • List three tools or strategies used to improve teamworkand build a safety culture.

  • State research and best practices in reducing infections, preventing central line infections, and going beyond the bundle.

© 2007 JHU Quality and Safety Research Group 2



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What is a Defect in Patient Care?

© 2007 JHU Quality and Safety Research Group 4

Definition-defect

A defect is any clinical or operational event or situation that you would not want to happen again. These could include incidents that you believe caused harm or put patients at risk for harm (Pronovost, P. et al., (2006) Tool tutorial: A practical tool to learn from defects in patient care Journal of Quality and Patient Safety, 32, 102-108.)


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Sources of Defects

  • Adverse event reporting systems

  • Sentinel events

  • Claims data

  • Infection rates

  • Complications

  • How is the next patient going to be harmed

© 2007 JHU Quality and Safety Research Group 5


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Complication, LOS, Charges*

*Miller JAMA 2003

© 2007 JHU Quality and Safety Research Group 6


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System Failures Can Come From Many Factors in an Organization

8 Major Factors that

can contribute to

System Failures

1.Institutional

2.Hospital

3. Departmental

4. Work 5.Environment

6. Individual Provider

7. Task Factors

8. Patient Characteristics

System Factors Impact Safety

7

© 2007 JHU Quality and Safety Research Group 7


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Safety Efforts Organization

  • Focus on Harm versus errors

    Harm- ignorance of causality- provider level

    Error see provider level

  • Proactive versus reactive

© 2007 JHU Quality and Safety Research Group 8


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LFD: A Four-step Process Organization

© 2007 JHU Quality and Safety Research Group 9

The LFD Process steps

  • Answers the question: “What happened?”

  • Evaluates the defect

  • Lists specific actions needed to reduce the likelihood the defect will happen again

  • How do you know the action taken got the results you wanted?


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Step 1. Answer-What happened? Organization

© 2007 JHU Quality and Safety Research Group 10

The Role of the investigator:

  • Construct a brief, concise statement of the “story” surrounding the incident.

  • Reconstruct the timeline of the incident or near miss

  • Try to “view the world” as one of those involved in the event at the time the event happened: How were those involved thinking about the problem? Why did they make the decision they made? Why did they take the course of action that was taken?


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Step 2. Evaluate the defect Organization

© 2007 JHU Quality and Safety Research Group 11

Evaluate the defect by

  • Reviewing and checking all the factors that caused or negatively contributed to patient harm,

  • Reviewing and checking all positive factors that might have reduced or eliminated harm


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Probes to Contributing Factors: Examples Organization

© 2007 JHU Quality and Safety Research Group 12


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Probes to Contributing Factors: OrganizationExamples Continued

© 2007 JHU Quality and Safety Research Group 13


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Step 3. Create an Action Plan Organization

© 2007 JHU Quality and Safety Research Group 14

List specific actions to reduce the likelihood of the defect happening again.

-determine who will lead the defect investigation

-establish a follow-up date

-measure risk reduction using either a qualitative or quantitative measure.


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Step 3. Action Plan: Template Example Organization

Create a specific action plan to mitigate the occurrence of this type of incident or the near miss

© 2007 JHU Quality and Safety Research Group 15


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Step 4. OrganizationHow will you evaluate the impact of the intervention?

1.Develop a framework to assess the impact of the intervention.

2.What are your variables?

3.How will they be measured?

4.How long will you evaluate?

Utilize your clinical experts- often your frontline staff. If they don’t view it as important or effective it unlikely to be successful

© 2007 JHU Quality and Safety Research Group 16


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Step 4. OrganizationHow will you evaluate the impact of the intervention?

© 2007 JHU Quality and Safety Research Group 17

Example: VRE reduction

Developed a new policy and procedure for skin antisepsis.

After education and Implementation

1.Evaluate the staff’s knowledge of the policy and procedure.

2.Is the policy and procedure being adhered to by the staff?

3.Summary of the staff’s perception of the impact of the intervention in preventing the defect?


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Walk Through- Case Study 1 Organization

© 2007 JHU Quality and Safety Research Group 18


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  • Safety Tips: OrganizationTeam debriefings at change of shift or hand-offs.Time-outs for assessment prior to procedures.Checklist guidelines for complicated procedures.

CASE IN POINT…..This case involves a chronically, critically ill white male over 65 years of age admitted to the ICU with a GI neoplasm. He had undergone GI surgery during this hospital admission and at the time of this adverse event was mechanically ventilated, with multiple infusions, inatropes and vasopressors. Due to failure to wean from mechanical

ventilation, he underwent an uneventful percutaneous tracheostomy. During the first change of the patient’s percutaneous tracheostomy, the airway was lost, likely because the Shiley was placed in the subcutaneous tissue rather than the trachea, leading to hypoxia, hypotension, cardiac arrest and death. In reviewing the activities leading to this adverse event: (1) there was miscommunication between nursing staff and ICU team regarding the policy for trach replacement, resulting in a request for tracheostomy replacement; (2) surgical chief changed the trach after evening change of shift without adequate back-up; (3) surgical chief was unaware of patient’s worsening condition throughout the day and fellow was not aware of the planned trach change; (4) no verbal or written note given at change of shift noting difficulty of trach placement (done in OR); (5) neither the ICU attending (handling two

admissions at the time) nor the surgical attending were notified of tracheostomy change in progress; (6) incorrect replacement trach tube used and inadequate positioning of patient; (7) ICU and surgical care teams failed to diagnose inadequate placement of replacement tube over red rubber catheter, attributing no EtCO2 or breath sounds to large cuff leak.

SYSTEM FAILURES:

OPPORTUNITIES for IMPROVEMENT:

  • 2-5 minute debriefing between teams at change of shift or hand-offs.

  • All staff stop and have a time-out prior to performing a procedure to discuss plan and any risks.

Poor communication among teams.

Develop a step-by-step checklist for performing a tracheotomy; make it standard policy to perform with ICU attending present.

Standard policy and procedure for percutaneous tracheotomy replacement was not followed.

Surgical chief’s limited knowledge of trach placement difficulty, poor trach placement skills.

Proper debriefing and clear procedural guidelines.


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Case Number 2 Organization

  • Take a few minutes and familiarize with the case

  • Review the investigate a defect tool.

  • Discuss with your team

© 2007 JHU Quality and Safety Research Group 20


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Workshop Objectives Organization

  • Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety Program.

  • Describe the process used to identify and eliminate system defects.

  • List three tools or strategies used to improve teamworkand build a safety culture.

  • State research and best practices in reducing infections, preventing central line infections, and going beyond the bundle.

© 2007 JHU Quality and Safety Research Group 21