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On the CUSP: STOP BSI The Science of Improving Patient Safety. Learning Objectives. To understand that every system is designed to achieve the results it gets To know the basic principles of safe design of both technical and teamwork To understand how teams make wise decisions.

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Presentation Transcript
learning objectives
Learning Objectives
  • To understand that every system is designed to achieve the results it gets
  • To know the basic principles of safe design of both technical and teamwork
  • To understand how teams make wise decisions
the problem is large
The Problem is Large
  • In U.S. Healthcare system
    • 7% of patients suffer a medication error
    • Every patients admitted to an ICU suffer adverse event
    • 44,000- 98,000 deaths
    • Nearly 100,000 deaths from HAI
    • Approximately 30,000 deaths from CLABSI
    • $50 billion in total costs
  • Similar results in UK and Australia

Kohn To err is human

rand study confirms continued quality gap

Condition

Percentage of

Recommended Care Received

Low back pain

68.5

Coronary artery disease

68.0

Hypertension

64.7

Depression

57.7

Orthopedic conditions

57.2

Colorectal cancer

53.9

Asthma

53.5

Benign prostatic hyperplasia

53.0

Hyperlipidemia

48.6

Diabetes mellitus

45.4

Headaches

45.2

Urinary tract infection

40.7

Hip fracture

22.8

Alcohol dependence

10.5

RAND Study Confirms Continued Quality Gap

McGlynn et al, NEJM 2003; 348(26):2635-2645

how can this happen

How Can This Happen?

Need to view the delivery of healthcare as a science

how can we improve understand the science of safety
How Can We Improve?Understand the Science of Safety
  • Every system is perfectly designed to achieve the results it gets
  • Understand principles of safe design
    • standardize, create checklists, learn when things go wrong
  • Recognize these principles apply to technical and team work
  • Teams make wise decision when there is diverse and independent input

Caregivers are not to blame

system failure leading to this error
SystemFailureLeadingtoThisError

Communication between

resident and nurse

Inadequate training

and supervision

Catheter pulled with

Patient sitting

Lack of protocol

For catheter removal

Patient suffers

Venous air embolism

Pronovost Annals IM 2004; Reason

system factors impact safety
System Factors Impact Safety

Institutional

Hospital

Departmental Factors

Work Environment

Team Factors

Individual Provider

Task Factors

Patient Characteristics

Adopted from Vincent

evidence regarding the impact of icu organization on performance
Evidence Regarding the Impact of ICU Organization on Performance
  • Physicians
  • Nurses
  • Pharmacists

Pronovost JAMA 1999, 2002; Pronovost ECP 2001

systems
Systems
  • Every system is designed to achieve the results it gets
  • To improve performance we need to change systems
  • Start with pilot test one patient, one day, one physician, one room
principles of safe design
Principles of Safe Design
  • Standardize
    • Eliminate steps if possible
  • Create independent checks
  • Learn when things go wrong
    • What happened
    • Why
    • What did you do to reduce risk
    • How do you know it worked
2 year results from 103 icus
2 Year Results from 103 ICUs

Pronovost NEJM 2006

basic components and process of communication
Basic Components and Process of Communication

Elizabeth Dayton, Joint Commission Journal, Jan. 2007

icu physicians and icu rn collaboration
ICU Physicians and ICU RN Collaboration

% of respondents reporting above adequate teamwork

ICUSRS Data

teamwork tools
Teamwork Tools
  • Daily goals
  • AM briefing
  • Shadowing
teams make wise decisions when there is diverse and independent input
Teams Make Wise Decisions When There is Diverse and Independent Input
  • Wisdom of Crowds
  • Alternate between convergent and divergent thinking
    • Get from OR to balcony
don t play man down
Don’t Play Man Down

When you feel something say something

action items
Action Items
  • Pick one area and reflect on the systems that predict performance
    • Walk and observe the process
  • Work to standardize one process such as central line cart
  • Pilot test it
  • Ensure all staff know the science for improving patient safety
references
References
  • Berwick DM. A primer on leading the improvement of systems. BMJ 1996;132:619-22.
  • Langley G, Nolan K. The improvement guide: a practical approach to enhancing organizational performance. Hoboken, NJ: Jossey-Bass Publishers 1996.
  • Needham DM, Thompson DM, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004;32:2227-33.
  • Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033.
  • Pronovost PJ, Angus DC, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288(17):2151-2162.
  • Reason J. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000.