On the CUSP: STOP BSI The Science of Improving Patient Safety

1. On the CUSP: STOP BSIThe Science of Improving Patient Safety

2. 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

4. 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

5. 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

6. How Can This Happen? Need to view the delivery of healthcare as a science

7. 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

8. 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

9. System Factors Impact Safety Institutional Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Adopted from Vincent

11. Evidence Regarding the Impact of ICU Organization on Performance • Physicians • Nurses • Pharmacists Pronovost JAMA 1999, 2002; Pronovost ECP 2001

12. Aviation Accidents per Million Departures

13. 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

14. 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

15. Standardize

16. Line Cart Contents – 4 Drawers

17. Eliminate Steps

18. Create Independent Checks

19. 2 Year Results from 103 ICUs Pronovost NEJM 2006

20. Principles of Safe Design Apply to Technical and Teamwork

21. Basic Components and Process of Communication Elizabeth Dayton, Joint Commission Journal, Jan. 2007

23. ICU Physicians and ICU RN Collaboration % of respondents reporting above adequate teamwork ICUSRS Data

24. Teamwork Tools • Daily goals • AM briefing • Shadowing

25. 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

27. Don’t Play Man Down When you feel something say something

28. 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

30. 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.