Understanding Patient
Safety
Presented by Dr. Redouane Bouali
Canadian Patient Safety Institute (CPSI)
June 10th, 2010
Mission
To provide national leadership in building and
advancing a safer Canadian health system
Vision
We envision a Canadian health system where:
• Patients, providers, governments and others work together to build and
advance a safer health system;
• Providers take pride in their ability to deliver the safest and highest quality
of care possible; and
• Every Canadian in need of healthcare can be confident that the care they
receive is the safest in the world.
2
A Sad Story
Noisy place!!
• 65 years patient, in ICU
being dialyzed
• Two nurses signing over
• Patient experienced an
arythmia
• No body noticed the ECG
strip....
• No body could hear the
alarm Bell
KCI bed Rep
• He interrupted the nurses
sign off and asked if he
can bring his bed.
• The nurses suddenly
realized that the patient
was in cardiac arrest.....
• It was too Late!!!
Nosocomial infection outbreak
• Burn Unit
• Experienced outbreak
• MRSA and VRE
Serious concerns....
Security control at the
front door
Hand Washing
Mandatory!!!!
• Line infection!!!!
• A BIG CONCERN!!!
Results: Catheter infections
A very poor communication
• 24 years old man
medical student
• Visited ER for
abdominal pain
• Discharged after 36
hours with diagnosis
of Gastritis.
• Patient went again to
the ER for the same
problem
• Patient insisted to go
home because he
had important test to
do at the University
• Patient went to his
hometown...
Operated the same
night for Appendicitis
(After 10 days!!!)
Poor communication
• Patient two days post op when was
authorized to go home , while walking in
the parking crashed!!!!
• Died after 2 hours of CPR
• Parents devastated asked several times
for an explanation (head of Surgery, head
of Emergency, in the two hospitals ....)
• Finally after few months they went to the
Media,,,,,,
Overview
• Introduction to Patient Safety
• Systems vs. Person Approach
• The Safety Competencies
• The Role of the Clinician, Team and
Patient
• Strategies to Improve Patient Safety
• Conclusion
8
Background
•
The “Quality in Australian Health Care Study” (1995)
•
The U.S. Institute of Medicine published the report
“To Err is Human” (1999)
•
The British Report, “An Organization with a Memory”
from the National Health Service (2000)
•
National Steering Committee on Patient Safety’s
“Building a Safer System” (2002)
•
The Canadian Adverse Events Study (2004)
Canadian Adverse Events Study
Adverse Event (AE) is defined as:
“an unintended injury or complication that results in
disability at the time of discharge, death or
prolonged hospital stay and that is caused by health
care management rather than by the patient’s
underlying disease process.”
Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J et al. (2004).
The Canadian Adverse Events Study: The incidence of adverse events among
hospital patients in Canada. CMAJ, 170(11), 1678-1686.
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Canadian Adverse Events Study
Findings:
• 3,745 charts reviewed
• ~7.5% of hospital admissions involve adverse event;
37% of adverse events preventable
Extrapolation:
• Of ~2.5 million hospital admissions in Canada in 2000…
…185,000 experienced 1 or more adverse events
…70,000 of the 185,000 were determined to be
preventable
…between 9,000 and 24,000 deaths due to adverse
events could have been prevented
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Canadian Adverse Events Study
Deaths among patients
with preventable
adverse events
Extra hospital days
associated with
adverse events
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What We Know
Canadian Institute for Health Information
(2004)
• One in ten adults contract infection in hospital.
• One in ten patients receive wrong medication
or wrong dose.
• More deaths after experiencing adverse events
in hospital than deaths from breast cancer,
motor vehicle and HIV combined.
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Epidemiology of Harm
Study
Date of
admission
Number of hospital
admissions
Adverse event rate
(% admissions)
California
Insurance Study
1974
20864
4.65 *
Harvard Medical
Practice Study
1984
30195
3.7
Utah-Colorado
1992
14052
2.9
Australian
1992
14179
16.6
United Kingdom
1999
1014
10.8
Denmark
1998
1097
9.0
New Zealand
1998
6579
11.2
France **
2002
778
14.5
Canada
2000
3745
7.5
World Health Organization. (2004). World Alliance for Patient Safety: Forward programme 2005. Geneva, Switzerland:
World Health Organization. Retrieved from http://www.who.int/patientsafety/en/brochure_final.pdf
14
15
Definitions
Patient Safety - The reduction and mitigation of unsafe
acts within the healthcare system through the use of
best practices shown to lead optimal patient outcomes.
(Canadian Patient Safety Dictionary, 2003)
Adverse Events - Unintended injuries or complications
that are caused by health care management, rather
than the patient’s underlying disease, and that lead to
death, disability at the time of discharge, or prolonged
hospital stays.
(Baker et al., 2004)
Harm - An outcome that negatively affects a patient’s
health and/or quality of life.
(Canadian Disclosure Guidelines, 2008)
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Adverse Events
•
•
•
•
•
•
•
•
•
•
•
•
•
Delayed or missed diagnoses
Medication errors
Wrong side surgery
Wrong patient surgery
Equipment failure
Patient identity
Transfusion errors
Mislabeled specimen
Patient/resident falls
Time delay errors
Laboratory errors
Radiology errors
Procedural error
• Lost, delayed, or failures to follow
up reports
• Retention of foreign object
following surgery
• Contamination of drugs,
equipment
• Intravascular air embolism
• Failure to treat neonatal
hyperbilirubinemia
• Stage lll or lV pressure ulcers
acquired after admission
• Wrong gas delivery
• Deaths associated with restraints
or bedrails
• Sexual or physical assault
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Adverse Events vs. Critical
Incidents
• Not all negative patient outcomes are
“adverse events”
• Not all adverse events
are “critical incidents”
Critical incidents
are the most
serious preventable
adverse events.
Negative Outcomes
Adverse
Events
Critical
Incidents
18
What Patient Safety Is and Is Not
• It is NOT what most of us were thinking about
10 years ago
• It is NOT what ‘we have always done’
• It is the most significant change in the
healthcare system in over a century
• It is a new applied science
• It has forever changed the face of modern
healthcare
19
Risky Activities
(Adapted by Dr. Philip Hebert)
15,000 deaths/yr
Total Lives Lost per year
Dangerous
(>1/1000)
Regulated
Ultra-safe
(<1/100K)
100,000
Hospitalization
10,000
Driving
Offshore
Industry
Commercial airlines
Coal Mining
timber
Firearms
1,000
100
truckers
Rock
Climbing
for 25 hrs
10
1
10
100
1,000
construction
Bungee Jumping
Scuba diving
10,000
100,000
1,000,000
Number of encounters for each fatality
10,000,000
20
The Challenge
In health systems, the challenge is to
change the environment from one of
crisis and blame to that of learning
and improvement.
Emory Center on Health Outcomes & Quality
Partnership for Health & Accountability, July 2004
21
Determinants of Adverse Events
• The System
• The People
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Most problems are found in processes,
not in people.
23
A System Perspective
• A system can be described as:
A grouping of components, such as resources
and organization (structure) that act together
(process), to achieve a particular result
(outcome).
(Canadian Patient Safety Dictionary, 2003)
• “Clearly certain structure is needed; and equally
clearly, there is no way to change outcome except
through changing process, since outcome ‘tells
on’ process.”
Slee VN, Slee DA & Schmidt HJ (1996).
Slee’s Health Care Terms, 3rd edition.
St. Paul, MN: Tringa Press.
24
Sources of System Error
• Overall culture
• Education / training / experience
• System design / engineering
• Resource availability
• Demand / volume
• Throughput impedance
• Shift-work schedules
25
The Systems Approach
Reason, J., (2000), BMJ (320), 768.
26
The Systems Approach
“…though we cannot change
the human condition, we can
change the conditions under
which humans work.”
Reason, J. (2000). Human error: Models and management.
BMJ, 320(7237), 768-770.
27
The Person Approach
• Historically focused on individual
performance and not system issues
• Front line staff often not involved in the review
of an adverse event
• Partial or incomplete “solutions” that do not
fully resolve the underlying cause and leave
the organization vulnerable to reoccurrence of
the event
• Fear of reprisals drives important information
underground
28
What about professional
accountability?
Does a “system” approach mean that
individual practitioners are not
accountable for their actions?
Sources of Personal Error
• Skill-based errors
•
• Rule-based errors
• Knowledge-based error
30
The Person Approach
“Incompetent people are 1% of the problem.
The other 99% are good people trying to do a
good job who make very simple mistakes and
it's the processes that set them up to make
these mistakes.”
Dr. Lucian Leape, Harvard School of Public Health
31
Person vs. Systems Approach
Person
Systems
• Errors are the result of
human failures
• Begin with the premise that
anything can and will go wrong
• Humans generally
perform flawlessly
• Don’t expect humans to perform
perfectly
• Perfect performance is
the expectation
• Design systems accordingly in a
proactive way
• Use retraining and
punishment to root out
“bad apples”
• Collective preoccupation with
possibility of failure
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33
The Safety Competencies
Domain 1
Contributing to a culture
of patient safety
Definition: A commitment to applying core patient
safety knowledge, skills and values to everyday work
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Shared Accountability
-Just Culture“…it is about creating a reporting environment where
staff can raise their hand when they have seen a risk
or made a mistake…..where risks are openly
discussed between managers and staff.”
“…while we as humans are fallible, we do generally
have control of our behavioural choices.”
“…good system design and good behavioural choices
of staff together produce good results. It has to be
both.”
Marx D, Comden SC, Sexhus Z (2005). Our inaugural issue – in recognition of
a growing community.The Just Culture Community News and Views, 1(1).
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Safety Culture
Excessive blame prevents
recognition of error, impedes
learning and effective action to
improve safety.
36
Safety Culture
• “Join us in converting a culture of blame
that hides information about risk and error
into a culture of safety that flushes out
information to prevent patient injuries.”
(Leape et al, 1998)
• “A somewhat lethal cocktail of impatience,
scientific ignorance and naïve optimism
may have dangerously inflated our
expectations of safety culture.”
(Cox & Flin, 1998)
37
Culture as Awareness
• Awareness of error and harm
• Willingness to discuss openly
• Open and fair culture
• Open disclosure
• Essential foundations
38
Culture
• Teamwork
• All focused on accomplishment of mutual
goals
• Aim for high-quality performance
• When something goes wrong…
– The focus is on what happened, rather than “who
did it”
– Atmosphere of how do we find the issues /
weaknesses and solve them
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The Safety Competencies
Domain 2
Work in teams for patient safety
Definition: Working within interprofessional teams to
optimize patient safety
40
Teamwork in Healthcare
• Healthcare must “establish team
training programs for personnel in
critical care areas . . . using proven
methods such as the crew resource
management training techniques
employed in aviation”
(Kohn et. al, 2000)
41
The Safety Competencies
Domain 3
Communicate effectively
for patient safety
Definition: Promoting patient safety through effective
health care communication
42
Communication / Team Work
Why is it critical?
• Nearly all instances of unexpected
adverse events involve communication
failures
• Joint Commission sentinel event data more than 2400 serious case analysis
revealed communication failures were
root cause in over 70%
43
The Safety Competencies
Domain 4
Manage safety risks
Definition: Anticipating, recognizing and managing
situations that place patients at risk
44
Clinicians Create Safety
• Err on the side of safety – speak up and ask
questions. Be safe first and brave afterwards.
• Be obsessive about hand washing. Be very
aware of why we need to do this and less
irritated about the time it takes.
• Have enough humility to recognize when you
are out of your depth. Be willing to ask for
help and receive help.
• Assess the situation and Be prepared to
Complete the task.
45
Teams Create Safety
• Make it clear what protocol or plan is being
used.
• Messages and communications are
acknowledged and repeated by those who
receive them.
• Team members are aware of other’s actions
and are ready to step in to support and assist.
• Team members support and monitor each
other.
• Speak up when a patient is at risk.
46
Patients Create Safety
• Speak up if you have questions of concerns,
and if you don’t understand, ask again. It’s
your body and your health, you have a right
to know.
• Pay attention to the care you’re receiving.
Make sure you’re getting the right treatments
and medications. Don’t assume anything.
• Notice whether your caregivers have washed
their hands. Don’t be afraid to remind them
to do this.
47
The Safety Competencies
Domain 5
Optimize human and
environmental factors
Definition: Managing the relationship between individual
and environmental characteristics to optimize patient
safety
48
Strategies to Improve
Patient Safety
• Hand hygiene
• Human factors engineering
• Safer Healthcare Now interventions
•
•
•
•
•
•
•
•
•
Improved care for Acute Myocardial Infarction
Prevention of central-line associated bloodstream infection
Medication reconciliation (Acute care/Long-term care)
Rapid response teams
Prevention of surgical site infections
Prevention of ventilator-associated pneumonia
Antibiotic resistant organisms (MRSA)
National collaborative on falls in long-term care
Venous thromboembolism
• Governance for safety and quality
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10 Patient Safety Tips
-Healthcare ProfessionalsCommunication:
1. Introduce yourself to your patients and let
them know that you invite them to bring any
concerns to your attention
2. Don’t allow patient and family concerns to go
unresolved
3. Listen! Listen! Listen!
4. Maintain Situational Awareness (be alert,
follow your intuition)
5. Participate in the implementation of a
common communication tool (e.g. SBAR)
10 Patient Safety Tips
-Healthcare ProfessionalsBehaviours / Competencies:
6. Use recommended patient safety practices
7. Understand where and how to report adverse
events
8. Participate in the testing of new devices
9. Be aware of your own limitations (e.g. fatigue,
biases)
10. Seek out information about patient safety
and incorporate it into your practice
The Safety Competencies
Domain 6
Recognize, respond to and disclose
adverse events
Definition: Recognizing the occurrence of an adverse
event or close call and responding effectively to
mitigate harm to the patient, ensure disclosure, and
prevent recurrence
52
Understanding Harm
• Definitions
Canadian Disclosure Guidelines CPSI
53
54
Safety is in Your Hands
We will NOT solve the problems of safety
by assuming they are “just the risks” inherent
in healthcare or by blaming someone.
Neither will solve the issues.
ONLY THROUGH OUR SYSTEMATIC EFFORTS
CAN WE IMPROVE SAFETY FOR THE
PATIENTS, CLIENTS, AND RESIDENTS THAT
WE CARE FOR
CPSI - Strategic Direction
• Click to ad text
CPSI - Areas of Focus
Education
Executive Patient Safety Series
Simulation
Halifax Conferences
Canadian Patient Safety
Officer Course
Research
Mental health
Home care
Long Term Care
Building Capacity
through Research
Patient Safety Competencies
---------------------------------------------------------Interventions & Programs
Tools & Resources
World Health Organization High 5’s
Root Cause Analysis
Electronic Health Record
Canadian Disclosure Guidelines
Patients for Patient Safety
Human Factors
Culture of Patient Safety
Canada’s Hand Hygiene Campaign
Safer Healthcare Now!
Canadian Adverse Event Reporting
and Learning System
Safe Surgery Checklist
What more could CPSI bring?
Contribution to physician engagement
Safe Surgery Checklist – done!
Safe Prescribing Checklist- potential?
Safety/Pharma clips – potential?
Système et processus intégrés
Saisie de données manuelles est
réglée par des gestes normaux du
personnel médical
hôpital
Bureau/unité
recherche
ADT
LABS
Pharm
Futur
fin 2010
maison
envois HL7
VPN
Réseau interne
Externe à l’hôpital
Ventilé, Cathéters,
Microbiologie, Labos
Seuil critique
Avertissement
Retour à une norme acceptable
Norme acceptable
• Valeurs et alertes personnalisées par l’utilisateur
• changements/mise à jour automatiques
personnalisables
Évolution des 10 dernières
meures
Summary
• Patient safety is everyone’s responsibility
• Understanding the problem is the first
step towards improvement
• When errors are viewed as an opportunity
for improvement rather than punishment,
patients will benefit
Vincent et al, (1998). BMJ, 316, 1154-7.
61
Take Home Message
“…there are some
patients we cannot
help, there are
none we cannot
harm...”
Arthur Bloomfield, M.D.
Quality of Healthcare in America Project 2003
-----Dr. Ken Stahl
62
Thank You…
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