In 3 sentences:
The document discusses patient safety in the VA system and why focusing on patient safety is important. It provides statistics on the size of the VA system and notes that medical errors harm millions of people each year, costing billions of dollars. The document advocates using a systems approach and human factors engineering to improve patient safety, rather than just policies or individual blame, in order to have the biggest impact on preventing future harm.
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Presentation at 2007 Meeting of Indian Health Service in San Diego
1. Patient Safety:
Why Bother?
Noel Eldridge, MS for
James P. Bagian, MD, PE
Chief Patient Safety Officer
Director, VA National Center for Patient Safety
February 28, 2007
james.bagian@va.gov & noel.eldridge@va.gov
www.patientsafety.gov
2. (Jimi couldnât make it today. You got Noel.)
James Bagian, MD, PE
Director, VHA National Center for Patient Safety
Noel Eldridge
Executive Officer, NCPS
3. VA Statistics (FY 2005)
ďŽ 7.7M enrollees, 5.3M uniques
ďŽ VA Medical Centers (Hospitals): 156
ďŽ Admissions: 587,000
ďŽ Community Based Outpatient Clinics: 708
ďŽ Outpatient Visits: 57.5M
ďŽ Rx Dispensed (30-day equiv): 231M
ďŽ Lab Tests: 215.9M
ďŽ Total FTE: 197,800
4. Veterans Health AdministrationVeterans Health Administration
2211 Veterans Integrated Service NetworksVeterans Integrated Service Networks
I J 2 0 0 2N A N U A R Y
W E R E IN T E G R A T E D A N D
R E N A M E D
V IS N 1 3 1 4
V IS N 2 3
S A N D
6. Institute of Medicine Goals
1. Safe â âavoiding injuries to patients from the care
that is intended to help themâ
2. Timely
3. Efficient
4. Effective
5. Equitable
6. Patient-Centered
ďŽ (from Crossing the Quality Chasm, 2001)
7. NY Times and W. Post This Week
ďŽ Medication Reconciliation & Adverse Events
â âUnintentional drug poisonings accounted for
nearly 20,000 deaths in 2004, said the CDC,
making the problem now the second-leading
cause of accidental death in the United States,
after automobile accidents.â
⢠W. Post â 2/27/07
â âIn August 2006, the Institute of Medicine of the
National Academies released a major study on
medication errors in American hospitals that found
that adverse drug events harm more than 1.5
million people and kill several thousand a year,
costing at least $3.5 billion annually.â
⢠NY Times â 2/25/07
8. Where Healthcare Was/Is
ďŽ Cottage Industry Mentality
ďŽ Virtually Total Reliance on:
â Professional/Individual Responsibility
â Individual Perfection
â Train and Blame
ďŽ Little Understanding of Systems
Relative to People and Processes
â Ignorance vs. Arrogance
Culturally Different!!!!
9. Where Does a
Culture of Safety Exist?
ďŽ Would you agree to fly on a bankrupt
airline to save $100?
ďŽ Would you agree to get elective surgery
at a bankrupt hospital to save $100?
ďŽ Are your answers different? If so, why?
ďŽ Do you trust the airline âsystemâ of
regulators, managers, pilots, and
mechanics in a different way than you
trust the healthcare âsystemâ?
10. Sad Comment at amazon.com
Take this Book to the Hospital With You:
A Consumer Guide to Surviving Your
Hospital Stay
(4.5 stars)
ďŽ by Charles B. Inlander
Buy this book with
How to Get Out of the Hospital Alive
(4.5 stars)
ďŽ by Sheldon P. Blau, Elaine Fantle Shimberg today!
ďŽ Buy Together Today: $20.34
CAN YOU IMAGINE THE EQUIVALENT FOR AN AIRLINE TRIP?
11.
12. NAVAL AVIATION MISHAP RATE
776 aircraft
destroyed in
1954
FY 50-96FY 50-96
Fiscal Year
2.39
39 aircraft
destroyed in
1996
0
10
20
30
40
50
60
50 65 80 96
Angled Carrier Decks
Naval Aviation Safety Center
NAMP est. 1959
RAG concept initiated
NATOPS initiated 1961
Squadron Safety program
System Safety
Designated Aircraft
ACT
HFCâs
ClassAMishaps/100,000FlightHours
13.
14. Three Important Questions
1. What Happened?
2. Why Did it Happen?
3. What Should We Do to Prevent it from
Happening Again?
15. Typical Healthcare Approach
ďŽ New Policies, Regulations,Reporting
Systems, Training
ďŽ Good First Step ButâŚ..
â Lack of Systems Insight
â Superficial Solutions (?Answers)
â Inadequate Follow-Up
â Lost Opportunity
16. Goal Selection
ďŽ Clear
â Not Confused With Tactics
ďŽ Compelling
â Relevance To Those Who Must Take Action
â Early Stakeholder Involvement in Goal Definition
ďŽ Reinforced By Leadership
â Visible Participation
⢠All levels â not hierarchical
17. Goal: Prevent Harm
VA Patient Safety Advisory - August 8, 2000
ďŽ Item: Medtronic Dual Chamber Temporary
Pacemaker model 5388
ďŽ Specific Concerns: The Medtronic Dual Chamber
Temporary Pacemaker model 5388 may become
inactive if a button is touched while it is in "self test"
mode. If this occurs the pacemaker display freezes,
will not work properly and displays an error code of
0004. At this point the pacemaker cannot be turned
off. In order to correct the situation the battery
drawer has to be opened. Only removal of the
battery clears the error and turns the pacemaker off.
It may then be restarted.
18. Typical Missing Features
ďŽ Clear Understanding of Goal
ďŽ Preventive Approach
ďŽ Field Understanding & Buy-In
ďŽ Systems Approach
ďŽ Sustainability
ďŽ Trust/Culture of Safety
19. Safety System Design
ďŽ High Reliability Organizations
ďŽ Role of Reporting
â Learning or Accountability?
ďŽ Systems-Based Solutions
â Patient Centered â DUH!!!!
ďŽ Importance of Close Calls
20. VA Patient Safety Data & Feedback
ďŽ Incidents reported have monotonically
increased since reporting to NCPS
started in 2000.
ďŽ VA inpatient mortality down ~35%
from 1999 to 2006.
â (Remember: âCorrelation is not causation.â)
21. VA Annual Events Reported
(including close calls) is Still Going Up
26. Most VA Reports are Actual âSAC 1sâ
(events with little or no harm, or close calls)
27. Which Events get RCAs?
ďŽ Many RCAs
are done on
events that
are not
Actual 3s.
ďŽ Numbers are
surprisingly
constant
since 2001.
ďŽ Is fewer
actual SAC3s
since 2001 &
2002 good
news?
Maybe.
28. RCA Categories (Coded by NCPS)
Selected Event (FY 2005) for Individual RCAs Percent
Fall 13.9%
Delay in Treatment/Diagnosis/Surgery 10.7%
High Alert Adverse Drug Events 10.5%
Unexpected Death 7.2%
Misidentification 6.3%
Missing Patient 4.9%
Hospital Acquired Infections 4.7%
Outpatient Suicide 3.4%
Correct Surgery 3.3%
65.0%
29. What about the Adverse Events and
Close Calls that donât get âRCAedâ?
ďŽ In VA Aggregated Reviews are
performed at the local level, one per
quarter on:
1. Adverse Drug Events
2. Missing and Wandering Patients
3. âParasuicidalâ Events
4. Falls
â (When they are not âSAC 3â events)
30. Guiding Principles For Patient
Safety System
ď§Learning, Not Accountability System
ď§Reporting System Characteristics
⢠Non-punitive - Confidential and De-identified
⢠Internal and External
ď§Importance of Close Call
ď§Reports Should Emphasize Narratives
ď§Interdisciplinary Review Teams
ď§About Identifying Vulnerabilities NOT
Statistics
ď§Prompt Feedback
ď§Open to All Comers
31. What comes from RCAs?
1. Local Fixes and Learning
2. Local Insight into Better Methods for
Improvement and the Tractability of
Problems (not like the weather)
3. VA-wide Alerts and Advisories
4. Systemwide Learning and Informed
policymaking
32. VA RCA data on Incorrect Surgical
Procedures (2001 â 2005)
ďŽ In-Operating Room: 33%
ďŽ Out-of-Operating Room: 42%
ďŽ Eye Procedures (can be either setting): 25%
33. What was Wrong? (2001-2005)
26 27
16
10
22
0
5
10
15
20
25
30
Wrong
Patient
Wrong
Side
Wrong
Site
Wrong
Procedure
Wrong
Implant
Percent
EXAMPLESâŚ
Patient: Similar
Diagnosis or
Name
Side: Other
Side Similar
Diagnosis
Site: On Spine
or Hand/Wrist
Procedure:
Biopsy vs.
Cystoscopy
Implant: Lens
34. VA RCA data on Retained
Surgical Items, 2000-2005
Sponge
, 52
Towel,
5
Other,
8
36. Safety & Human Error:
Challenges
ďŽ Healthcare Views Errors as Failings
Which Deserve Blame - Fault
ďŽ Train and Blame Mentality
ďŽ Blind Adherence To Rules
ďŽ Corrective Actions Focusing on
Individual
ďŽ No Blood No Foul Philosophy
37. Safety & Human Error:
Cornerstones
ďŽ People Donât Come to Work to Hurt
Someone or Make a Mistake
ďŽ Must Keep Asking âWhy?â
38. Safety â Human Error
Technical
Individual
Team
Profession
Institution
Policies/Procedures
Accident
LATENT
FAILURES
DEFENSES
Incomplete
procedures
Regulatory
narrowness
Mixed
Messages
Production
pressures
Responsibility
shifting
Inadequate
training
Attention
Distractions
Clumsy
Technology
Deferred
Maintenance
39. Patient Safety - Strategy
ďŽ Invite People to Play
â Problem Recognition
â Remove Barriers (Punitive, Difficulty, Black
Hole Effect)
â Learning NOT Accountability System
ďŽ Importance of Close Call
ďŽ Blameworthy Definition
ďŽ Training (Middle thru Top Management)
Leadership At All Levels
ďŽ Human Factors Approach
â Tools That Guide Behavior
41. Prioritize
ďŽ Risk Based
â Severity
â Probability
ďŽ Must Make Sense
â Business Processes
â Regulatory Environment
42. Systematic
ďŽ Cause and Effect
ďŽ Human Error Must Have Preceding
Cause
ďŽ Failure to Follow Procedure By Itself Is
NOT a Root Cause
ďŽ Negative Descriptors Arenât Actionable
ďŽ Failure To Act Is not Cause Without
Pre-existing Requirement To Act
ďŽ Why,Why,Why
43. Causation/Actions:
Who vs.What &Why
ďŽ Who
â âWhose Fault Is This?â
â Actions focused on correcting individual
â âCorrectsâ only after problem occurs
â Limited scope of action and generalizability
ďŽ What & Why
â Actions focus on systems level causation
â Widespread applicability
â Stronger preventive strategy
44. Intentionally Unsafe Acts
ďŽ ââŚevents that result from: a criminal act; a
purposefully unsafe act; an act related to
alcohol or substance abuse by an impaired
provider and/or staff; or events involving
alleged or suspected patient abuse of any
kind.â
ďŽ Intentionally Unsafe Acts are off-limits to
Patient Safety (RCA) review, everything else
is within limits
47. This was not an aerobic exercise
ďŽ Demonstrates: âpaired associate
learningâ
48. Medical Software Correlation
- Pharmacist uses 95% of time.
- âEnterâ button enters data.
- Pharmacist uses 5% of time.
- âSpacebarâ enters data.
49.
50.
51.
52.
53. âTake-awayâ on Human FactorsâŚ
ďŽ Considering and acting on knowledge
regarding human capabilities,
limitations, and tendencies when
designing and operating devices and
systems
ďŽ Not always âcommon senseâ
54. Human Factors Engineering
and âActionsâ
ďŽ Warnings and labels (watch out!)
ďŽ Training (donât do that)
ďŽ Procedure changes (work around that)
ďŽ Interlock, lock-in, lock-out, etc (let me
design it so you can not do that â forcing
functions)
ďŽ Is there one right action???
Weaker
Stronger
56. Stronger
Actions
⢠Architectural/physical plant changes
⢠New devices with usability testing before purchasing
⢠Engineering control or interlock (forcing
functions)
⢠Simplify the process and remove unnecessary steps
⢠Standardize on equipment on process or caremaps
⢠Tangible involvement and action by
leadership in support of patient safety
Intermediate
Actions
⢠Redundancy
⢠Increase in staffing/decrease in workload
⢠Software enhancements/modifications
⢠Eliminate/reduce distractions (sterile medical
environment)
⢠Checklist/cognitive aid
⢠Eliminate look and sound-alikes
⢠Readback
⢠Enhanced documentation/communication
Weaker
Actions
⢠Double checks
⢠Warnings and labels
⢠New procedure/memorandum/policy
⢠Training
⢠Additional study/analysis
61. Alert based on âwrong-tubeâ RCAs
ďŽ Veterans Health Administration Warning System
ďŽ Published by VA Central Office
ďŽ AL06-012 April 6, 2006
â Item: Mix-up (wrong route of administration) of bladder
irrigation with intravenous (IV) infusions
â Specific Incidents: Since 2001, VA facilities have reported
five cases of accidental infusion into an IV line or PICC line.
Amphotericin B (Attachment #1) was given intravenously
when it was intended for irrigation of the bladder via a
catheter. The same adverse event could occur with Glycine.
Amphotericin B and Glycine are both contraindicated in
patients with kidney or liver disease and when Amphotericin
B is infused via IV line, it can induce serious complications
(e.g., kidney failure).
63. Redundancy vs. Double-check
in Spelunking (Caving)
ďŽ Two choices of
equipment
1. One flashlight ď
batteries checked twice
2. One flashlight ď and
one headlamp
70. Is There A Business Case?
ďŽ YOU BET!!!
ďŽ Examples:
â âEasy CAPâ CO2 Detector
⢠$154/detected esophageal intubation
â RCA/40person-hrs X 12RCA/yr
⢠0.25FTEE
71. Devices to prevent Out-of-OR Esophageal
Intubations are Cost-Effective
Description Equation =
Numerator Cost to implement (11,000
[# of codes] x $10)
$110,000
Denominator Number of recognized
events (assuming 100%
prevention effectiveness)
715
Cost-Effectiveness
Measure
$110,000 / 715 $154
Interpretation
It will cost $154 to detect one
unanticipated esophageal intubation
($10 per use at a rate of 6.5%)
72. Benefit-Cost of Patient Safety
ďŽ National Center for Patient Safety,
Regional Patient Safety Officers, Facility
Patient Safety Managers, Local RCA
teams
~$130k per VA Medical Center (0.1%)
If this is a VA facilityâs budget
This is Patient
Safetyâs Share
73. Some Interventions have Zero Cost
Use of Antimicrobial Soap in VAMCs
43
19
38
3 16
81
0
10
20
30
40
50
60
70
80
90
Use Antimicrobial
Soap Only
Use Non-
antimicrobial
Soap Only
Use Both Types
of Soap
Percent(N=~120)
Dec-03
May-04
See Hand Hygiene Tools on www.patientsafety.gov
75. Sustainable Systems Approach
ďŽ Problem Identification
ďŽ Clear Goal Definition
ďŽ Involvement Of All Sectors
ďŽ Identify Systems Influences
ďŽ Identify Systems Controls
ďŽ Identify Constraints
ďŽ Critique â Go To Worst Critics Early On
ďŽ Pilot â Volunteers First Then Others
ďŽ Evaluate
76. Critical Elements
ďŽ Safe for Reporters/Participants
ďŽ Prioritization Method
ďŽ What is Blameworthy
ďŽ Not About Fault â 3 Wâs
ďŽ Human Factors Engineering Tools
â Triage Cards, RCA Method
ďŽ Concur/Not Concur (Mgmt/Leadership)
ďŽ Feedback
ďŽ Dedicated Patient Safety Duties
77. Closing Thoughts
ďŽ Not About Errors!!!
ďŽ Counting reports is not the objective,
identifying Vulnerabilities is
â Hope they increase
âAnalysis, Action, & Feedback
are the key
ďŽ Prevention NOT Punishment
ďŽ Cultural change is the key â takes time
ďŽSafety is the Foundation
Upon which Quality is Built
78. Safety as the Foundation?
ďŽ Quality programs can ensure that we use
evidence-based medicine to determine
which cardiac patientsâŚ
â Are prescribed the most appropriate of many
medications, and/or
â Get angioplasty with or without drug-eluting or
bare metal stents, and/or
â Get CABG surgery
ďŽ But if they get surgical site and/or urinary
tract infections, and/or fall in the hospitalâŚ
â Can you call this High Quality Care???
79. Why Bother?
1. The Problem is Real
2. You Can Do Things to Make it
Better
âThey say that time changes
things, but you actually have to
change them yourselfâ
Andy Warhol
80. Recently we have received a number of questions about whether is
it legal to buy facial tissues. At issue is whether or not the facial tissues are considered personal items.
We have discussed this issue with Department logistic and financial staff as well as VHA clinical staff.
The following provides a basis for the decision that was reached:
For patient-care areas and areas frequented by those who come in direct contact with patients, facial tissues should be considered
similarly to other expendable supplies that VA workers may use as they perform their duties during work hours. For example, VA
supplies disposable respirators, gloves, and surgical scrubs and gowns, all of which are employed by staff to protect patients from the
spread of infectious agents. This type of expenditure is clearly appropriate. On the second point, recent guidance from the CDC,
JCAHO, the National Health Information Center of the Department of Health and Human Services, and the American Lung Association
have all included recommendations for using tissues to cover coughs and sneezes to prevent the spread of infectious agents. First
among these infectious agents are viruses that cause upper respiratory infections such as cold and flu, but another agent of concern is
Staph. aureus (SA), including methicillin-resistant SA (MRSA), either of which can cause skin and wound infections. Various estimates
put the percentage of healthcare workers whose nasal passages are colonized with SA at about 30-40%. (The percent colonized by
MRSA is not well described and seems likely to vary widely.) SA and MRSA can be expelled from the nose during a sneeze and live for
days or weeks on substrates such as clothes, linens, curtains, countertops, and other environmental surfaces where they can be picked
up on hands or transferred to other surfaces and eventually patients. Using a tissue to reduce the dispersion of droplets and the gross
contamination of hands or clothes is imperfect but is widely recommended as a basic measure to control the spread of infectious agents.
Conclusion: Facial tissues to be used in patient care areas and
areas frequented by those who come in direct contact with patients
can be purchased with appropriated funds. This memo should not be taken as a mandate
to generate any new requirement to provide tissues in specific locations or at any pre-set density. Decisions on this topic should be
made locally and incorporate local circumstances and considerations.
(Agreed upon by: Fiscal, Accounting, Legal, Network Clinical
Managers, Public Health, Environment of Care, Infectious
Diseases, Patient Safety, in about 3 weeks.)
81. Are we there yet?
âFrom a certain point forward there
is no longer any turning back. That
is the point that must be reachedâ
- Franz Kafka
I look a little more like Noel Redding than he does like Jimi Hendrix.
Bankrupt or nearly bankrupt airlines: United, US Airways, ATA. Is there really such a thing as â The Healthcare System â Consider adding chart on definition of system.
This first book has been in print for at least 15 years. Isn â t this kind of embarrassing? Would anyone fly on an airplane if there was a market for books like this?
All reporting - is in the end - voluntary
Do 4 or 5 times. Hit table the same time. Last time only hit table (some will raise hands).
Pattern recognition. Taking shortcuts. Do we have any systems where we do repetitive actions that might have more than one action? Demonstrates a low level brain response. Training yields a low level auto response, telling someone not to do something under these conditions won â t be effective.
Not a lot of evidence that this made things better. But who knows, reporting of lawnmower accidents probably is not the most accurate
NOTE: The $5.2M figure does NOT include PSRS. The raw budget figure for the office is $8.278m for FY05.