Case Study
&
Tools Integration
James (Jeb) Buchanan, M.D.
Fort Wayne Med Ed Program
Betsy Lee, RN, BSN, MSPH
Patient Safety and Quality Consultant
Tools for Sensemaking (Weick and Battles)
• Literally “making sense of events”
• Building a systems understanding to eliminate
and mitigate risks to patients
• True sensemaking is reactive and proactive
• Focus of learning organizations – systematically
increasing reliability
• Provides data-driven framework for sensemaking
through tools and joint reflection
• Importance of staff engagement and curiosity
Retrospective Sensemaking Tools
• Root Cause Analysis
• Visualizing – Causal Tree
• Data Mining
Root Cause Analysis (RCA)
• What is a ‘Root Cause Analysis’?
– Reactive Assessment of basic or contributing
causal factors associated with a specific event
– Analysis focused primarily on system and
process issues rather than assigning individual
responsibility
– Process for identifying the basic or contributing
causal factors associated with adverse events
or close calls
Root Cause Analysis (RCA)
• When is a Root Cause Analysis (RCA)
Required/Recommended?
• Joint Commission Reviewable Sentinel Event
• Events that have caused or could cause serious
disability or death to patients
• Clusters of similar events or near misses that have
potential for harm (e.g. Aggregated Review or
Common Cause Analysis)
Root Cause Analysis
Ask why x 5
Root Cause Analysis (RCA)
Event Occurs
Take Immediate Action
Complete Root Cause Analysis
Flow Diagram
Ask “5 Whys”
Enter Event into
Patient Safety
Information System
Cause and Effect Diagram
Root Cause Statements
Implement Corrective Action
RCA
Required?
Evaluate Corrective Action
Against Goals
Immediate Action Required
• When is ‘Take Immediate Action’ required prior to
beginning the RCA?
– Preventing further harm to patient(s) and/or staff
members
– Notifying police
– Preserving evidence or information that will aid in the
RCA process
– Others??
– Examples??
Hierarchy of Actions
Prospective Sensemaking Tools
• Healthcare Failure Mode and Effects
Analysis (HFMEA)
• Probabilistic Risk Assessment (PRA) –
adds probabilities to HFMEA
Latent Errors
FMEA
Failure Mode Effects Analysis
Swiss Cheese Model
Case Review Sheet
MegaTool
Handout #2
Use of templated Case Review Sheet
– Systematically drives process
– Non-reliance of memory of what to consider
– Educational/Documented
Case Review Sheet
MegaTool
• Peer Review Scoring
• Failure Analysis Tool – Human Factors and
Systems
• Diagnostic Failure – Heuristics/Affective Bias
• Teamwork (TeamSTEPPS) principles
• IOM/IHI Principles
• ACGME/AOA Competency Breaches
• Patient/Family Engagement
• WHO & TeamSTEPPS
• Just Culture – Modified Reason’s
• Hierarchy of Actions – VA National Center for
Patient Safety
• Level 4/5 system-based competency
Case Revisited
• Break into small groups
• Determine contributing human factors
and system errors
• Complete Case Review Sheet
Handout #2
What human factor was involved
when nurse grabbed the wrong
medicine bag?
1. Similar
sequencing
2. Oops maneuver
3. Pattern Matching
4. Cognitive delay
Response
Counter
0%
1
0%
2
0%
3
0%
4
12
Nurse obtaining epidural solution
without order is an example of:
1. Disinterest
2. Walk-a-Round
3. Cognitive
Sequencing
4. Memory
Impairment
Response
Counter
0%
1
0%
2
0%
3
0%
4
14
Was nursing service chronically obtaining
the epidural solution before order
obtained to place an epidural an example
of normative deviation?
1. Yes
2. No
Response
Counter
0%
0%
10
1
2
Normative Deviation
Was this individual error,
systems error or both?
1. Individual
2. Systems
3. Both
0%
Response
Counter
1
0%
2
0%
3
11
Nurse working more than 12 hours
increased her error by how much?
A.
B.
C.
D.
25%
33%
100%
300%
0%
Response
Counter
A.
0%
B.
0%
C.
0%
D.
13
Is anesthesiologist’s past passive aggressive
behavior considered disruptive, increase
hierarchical communication, and thus contribute
to team error?
1. Yes
2. No
0%
Response
Counter
1
0%
2
14
Did hospital’s medical staff permitting this
chronic behavior contribute from a
systems aspect?
1. Yes
2. No
0%
Response
Counter
1
0%
2
13
Is there more disruptive
behavior in medicine than
other industries?
1. More
2. Less
3. About the same
Response
Counter
0%
1
0%
2
0%
3
13
Do you think this hospital had
a Culture of Safety and Just
Culture?
1. Yes
2. No
0%
Response
Counter
1
0%
2
10
System Reengineering – Would making the
female and male ends of the IV tubing and
epidural catheter incompatible help prevent
human error from reaching the patient?
1. Yes
2. No
Response
Counter
0%
0%
10
1
2
Did the Swiss Cheese Model
Prevail?
1. Yes
2. No
0%
Response
Counter
1
0%
2
11
Commitment to Change
Statement
Swiss Cheese Model
Errors Will Occur
•
•
•
•
Prevent
Detect
Intercept
Mitigate harm
References – CME Effectiveness
1
Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician
performance: A systematic review of the effect of continuing medical education
strategies. JAMA. 1995;274:700-705.
2
Marinopoulos SS, Dorman T, Ratanawongsa N, et al. Effectiveness of
Continuing Medical Education; Agency for Healthcare Research and Quality
(US); January 2007.Available at:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1b.chapter.105720).
3
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the
21st Century. National Academies Press, 2001, page 13.
4
Balas EA, Boren SA. Managing Clinical Knowledge for Health Care
Improvement. In: Bemmel J, McCray AT, editors. Yearbook of Medical
Informatics 2000: Patient-Centered Systems. Stuttgart, Germany: Schattauer
Verlagsgesellschaft mbH; 2000:65-70.
References - Diagnostic Failure
•
•
•
•
•
•
•
"Addressing Diagnostic Errors: An Institutional Approach," Focus on Patient
Safety, Fall (www.npsf.org/paf/npsfp/fo/pdf/focus v13-3-2010.pdf)
"Why diagnostic errors don't get any respect -- and what can be done about
them," Health Affairs, September
(content.healthaffairs.org/cgi/content/abstract/29/9/1605)
"Thinking about diagnostic thinking: a 30-year perspective," Advances in Health
Sciences Education: Theory and Practice, September 2009
(www.ncbi.nlm.nih.gov/pubmed/19669916)
"Diagnostic Errors -- The Next Frontier for Patient Safety," The Journal of the
American Medical Association, March 11, 2009 (jama.amaassn.org/cgi/content/short/301/10/1060)
"Diagnostic Error in Internal Medicine," Archives of Internal Medicine, July 11,
2005 (archinte.ama-assn.org/cgi/content/abstract/165/13/1493)
"The importance of cognitive errors in diagnosis and strategies to minimize
them," Academic Medicine, August 2003
(www.ncbi.nlm.nih.gov/pubmed/12915363)
"Diagnostic Error in Medicine" annual meetings, Society for Medical Decision
Making (www.smdm.org/diagnostic_errors.shtml)
References - Diagnostic Failure
• Scott, I. Errors in Clinical Reasoning: Causes
and Remedial Strategies, BMJ, V339, 2009
• Bordage, G. Why Did I Miss the Diagnosis?
Some Cognitive Explanations and Educational
Implications, Acad. Med. 74(s)m 1999
• http://psnet.ahrq.gov/primer.aspx?primerID=12
(diagnostic errors)
• Society for Medical Decision Making
References - Diagnostic Failure
• Overconfidence in Clinical Decision Making;
Croskerry; American J. of Medicine (2008)
Vol 121 (5A), S24-S29.
• Diagnostic Errors: Why They Happen;
O’Reilly; AMANews; Dec. 6, 2010
• Diagnostic Failure: A Cognitive and Affective
Approach; Croskerry; Advances in Patient
Safety, Vol.2.
• Perspectives on Diagnostic Failure and
Patient Safety; Croskerry; Healthcare
Quarterly, 15 (Special Issue) 2012: 50-56.
References - Diagnostic Failure
• Patient Safety Strategies Targeted at
Diagnostic Errors – A Systemic Review;
McDonald, K., et. al.; Annals of Internal
Medicine; March 5, 2013; Vol. 158 N0. 5
Page 381-389.
• JAMA Internal Med, Newman-Toker, Makary,
Feb, 2013
References - Diagnostic Failure
25-Year summary of U.S. malpractice
claims for diagnostic errors 1986-2010: an
analysis from the National Practitioner
Data Bank, BMJ Quality & Safety,
published online April 22, 2013
References – Diagnostic Failure
• Seen Through Their Eyes: Residents’ Reflections on
the Cognitive and Contextual Components of
Diagnostic Errors in Medicine; Alexis R., et al.,
Academic Medicine. 2012; 87:1361-1367
• James, J A; New Evidence-based Estimate of Patient
Harms Associated with Hospital Care; Journal of
Patient Safety; Sept 2013;Vol 9 –Issue 3: 122-128.
References – Diagnostic Failure
• Using Functional MRI to Improve How We
Understand, Teach, and Assess Clinical Reasoning;
Durning S., et al., J. of Continuing Education in the
Health Professions, 34(1):76-82, 2014.
• Why Do Doctors Make Mistakes? A Study of the Role
of Salient Distracting Clinical Features; Mamede S.,
et al., Acad Med. 2014; 89:114-120
• Exposure to Media Information About a Disease Can
Cause Doctors to Misdiagnose Similar-Looking
Clinical Cases; Schmidt H; Acad Med. 2014; 89:285291.
References – Diagnostic Failure
• Deciding About Fast and Slow Decisions; Croskerry
P et al.; Acad Med. 2014; 89: 197-200.
• The Etiology of Diagnostic Errors: A Controlled Trial
of System 1 Versus System 2 Reasoning; Norman G,
et al.; Acad Med. 2014; 89: 277-284
References – Disruptive Physician
Behavior
• Joint Commission August, 2009 Sentinel
Event Alert
– http://www.jointcommission.org/sentineleve
nts/sentineleventalert/sea_40.htm
– AHRQ
http://www.psnet.ahrq.gov/search.aspx?se
archStr=disruptive+behavior
• AHRQ
– http://www.psnet.ahrq.gov/primer.aspx?pri
merID=15
References – Just Culture
• Patient Safety and the "Just Culture": A
Primer for Health Care Executives.
http://psnet.ahrq.gov/resource.aspx?resou
rceID=1582
• www.justculture.org
Further Resources
Patient Safety
• AAMC
– Te4Q = Teach for Quality
• Core Faculty training in patient safety and
quality improvement
• Faculty competencies in teach above
• www.aamc.org/te4q
Resources
Patient Safety
• IHI Open School
– Patient Safety training from Institute for
Healthcare Improvement
– For residents (no charge)
– Faculty also using
– www.ihi.org/openschool
– Also has a mobile app
Further Resources
Patient Safety
• Society of Hospital Medicine
– Quality Improvement Resource Rooms
– QI basics and clinical tools
– Quality and Safety Educators’ Academy
– Designed for faculty
– Also have an educational annual meeting
• Quality track
– www.hospitalmedicine.org
Further Resources
Patient Safety
• www.SafetyLeaders.org
Further Resources
Patient Safety
• Achieving Safe and Reliable Healthcare
– Leonard, M; Frankle, A; 2004; Health
Administration Press; ACHE
• ACPE Programs
– Three Faces of Quality
– Advanced Applications in Quality
Management
– Science of High Reliability: Building Better
Healthcare
Further Resources
• Reason J, Managing the Risks of
Organizational Accidents. Ashgate
Publishing; 1997; Fig 9.4 pg 209
• Nawotniak R, The Complete Residency
Program Guide. HCPro, Danvers MA; 2009;
Chapter 13, Fig 13.1, 13.2
• http://www.patientsafety.gov/ (hierarchy for
corrective actions)
Redesigned M&M
• Began Fall, 2009
• M&M peer review protected
– Extension of each hospital QI committee
• Initial two hour didactic on Human
Factors and System/Reliability Science
Redesigned M&M
Components
• Learning Activity Instruction Sheet
Handout # 7
– Checklist
– Review with Program Director to assure not
just an interesting case (which would be
better served at Grand Rounds)
– Need to have an error or near miss
• Use of templated Case Review Sheet -#2
Handouts/Learning Activity
• Faculty evaluation form with embedded
Goals & Objectives Handout # 8
• Resident peer evaluation – Handout # 9
• Resident self-assessment/reflection/ILP
Handout # 10
• Learning Portfolio
Redesigned M&M
Components
• Case Review Worksheet to hospital
(Institution) QI department
– Peer protected
– Prioritize hospital/Institution patient safety
projects
– Medical staff quality committee meeting.
– Residents follow through with active
participation in the interdisciplinary team.
• 2 resident members and PD on hospital QI
committee
GMEC/Institution Reporting
HO #11
• Quarterly reporting
• Peer Review Protected
• Pink Paper to prevent document leaving
GMEC meeting
Results
• Since 2009
– 100% residents achieved NAS Level 4
– 81% residents achieved NAS Level 5
– Usually by the end of PGY2
Further GME Patient Safety
Engagement
• Using Case Review Worksheet as onthe-fly reporting to Institution/hospital
quality department.
• Available on server for immediate
electronic access
• Identify patient quality, safety, and
waste with proposed solutions
– Critical thought - not just reporting
• Reinforces new skill set