A journey of small steps
 PRIMUM NON NOCERE
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I got started because many of the
speakers on this subject were MFMs like
myself
I was unhappy hearing incomplete
explanations for what hospital and
agencies were trying to do
If there needs to be greater safety I want
to be a leader
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In 1999 the Institute of Medicine reported that
medical errors may result in as many as 98,000
deaths a year, costing as much as 29 Billion
dollars, noting that “bad systems, not bad
people” are responsible
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Many high risk industries have had
problems with safety in the workplace. It
is their proven improvements which are
now being applied to healthcare
Back in the day, initial efforts focused on
improving individual behavior through
punitive measures for mistakes
This was an ERROR and
remains one
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Responding to errors with blame and
punishment will stifle future transparency and
impede system improvement
Willful violations and disruptive behavior cannot
be tolerated; met with escalating levels of
discipline
Flat hierarchy encouraging bidirectional
communications
Support of teamwork
Disclosure of events and apology to patients
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Safety systems are needed which will
anticipate human error
Checklists
Forging function and human factors into a
design whereby routine ways are found to
conduct high risk business
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Agencies that report adverse events
 Centers for Medicare and Medicaid
services ( CMS)
 Joint commission (JCAHO)
 NSQIP
 National surgical quality Improvement
program
 Healthcare personnel who disagree
with your management
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Groups that report on institutional and
individual quality
 Healthgrades
 Leapfrog
 US News and World Report
 National Practitioner Data Bank
 Specialty committees
 Patients and their Ubiquitous websites
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A meaningful result is a measurable
reduction in serious adverse outcomes
An improvement in efficient and cost
effective patient care
Protocols ( checklists) and systems which
are easy to learn and use
Respect for the majority of patient needs
with allowance for specialized needs for
clinical situation, culture, autonomy
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Learn from events to prevent future errors
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Correct medication Errors
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Improve healthcare strategies
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A culture of safety with implementation and
sustainability
COMMUNICATIONS
 Handoffs
 Team training
 Simulation training
 Rapid response from other healthcare
resources
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Individual Improvement nursing and
physician attitudes and practice
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Result of people, systems and processes
interacting to function as a whole toward a
common goal
Organizational culture is a set of shared
attitudes, values, goal and practice
 Shared assumptions and actions
developed by a group
 coping with internal and external problems
validating responses from past experiences
assumptions may be taught to new group
members
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Commitment to safety at the highest level
Necessary resources for safety are available
Safety is the primary priority
Effective communication about safety among
all workers is encouraged
Hazardous acts are rare
Transparency in reporting and discussing
errors
Safety solutions focus on system improvement
not individual blame
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Walk rounds – open-ended questions;
information in the database
Personnel problems for discussion
Equipment malfunctions
Event debriefings – all team members; did
everyone perceive the case the same way?
Was anyone overstressed and unable to get
help? Errors made and avoided. Assessment
of team functions
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Different perceptions of how best to care for the
patient
Conflicts that result from disruptive individuals
with intimidating behaviors
DESC
Describe
Express
Specify
Consequences
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HAI Healthcare Acquired Infections
1.7 million cases with 99,000 deaths
HHC Hand Hygiene Compliance
Unacceptably low among healthcare workers
and physicians
Physicians 5% to 89% average 38.7%
Efforts to improve overall rates of HHC have
not improved
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Medication systems to confirm dosage, drug,
frequency and method of administration is
correct and not inappropriate to allergy or
interaction
Standardization of preventive techniques and
checklist for high risk situations
Ease of ordering the correct drug with its
accessories ( needles and syringes)
Means of reporting errors which are not buried
in paperwork to avoid liability
CATEGORY
ORIGIN OF
ERRORS
PRESCRIBING
TRANSCRIBING
DISPENSING ADMINISTRATION
39%
12%
11%
38%
SOURCE
OF
HARM
28%
11%
28%
51%
ERRORS
INTERCEPTED
48%
33%
33%
2%
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Omission of a single dose
Giving the wrong dose
Giving the incorrect strength
Incorrect timing of the administration
Administration of the wrong drug entirely
Failure to report the error to the physician
In our series Oxytocin, antibiotics and Insulin
top the list
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Safety Solutions with standard contents
and infusion rates
Smart infusion intravenous pumps
Point of care bar code scanning
Computerized Order entry
Multiple checks from pharmacy and
nursing
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Look-alike and sound-alike medications
Verbal orders
Writing illegibility
Drug interactions and drug allergies
Education of patients regarding their
other medications and appropriate use
Risks and benefits of drugs and
interactions
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Different Pharmacies
“left-over meds”
Meds from family and friends
Street agents available for sale
Practice related Medication errors
Stressful, urgent multi-tasking errors
 Excessive use of verbal orders
 Multiple care providers with translational errors
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Problems arise from reluctance to notify one’s
supervising physician or manager is the root
cause of many errors and may be because of
fear of reprisal, overconfidence, or simple lack
of knowledge or experience
Healthcare workers’ future actions are shaped
by how leadership responds to an event.
Support the reporting of near missed and
adverse events and involve employees to
improve current work flow and practices
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SCIP – surgical Care Improvement Project
CMS – Centers for Medicare and Medicaid
Services
CDC – Centers for disease control and
Prevention
ACS – American College of Surgeons
AHRQ – Agency for Healthcare Research and
Quality
ACOG – American college of OB-GYN
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Infection the most common complication of OB
GYN surgery
Systemic antibiotics recommended since skin
is the usual site of inoculation
Prior to surgery aids natural host defenses and
works better than after skin incision
Adequate tissue and serum drug levels are
important so additional doses for longer
procedures, after greater blood loss, and
obesity
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Continuation of antibiotic postoperatively may
lead to emergence of bacterial resistance
In addition to antibiotics: effective surgical
scrubs; excellent surgical technique; preventing
hypothermia; Glucose control; limiting hair
removal; and smoking cessation
There is good evidence for prophylaxis of
major gyn surgery entering the vagina
No prophylaxis needed for bladder
catheterization, hysteroscopy, endometrial
biopsy or IUD placement
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Humans are hard wired for limited
communication capabilities
We do not hear and remember every utterance
We do not capture and reliably store words and
data like a computer
We frequently rely on the appearance of the
face
We make snap judgments
We subconsciously transmit our emphasis and
prejudice as part of a factual story
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How one perceives and understands their
environment
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Perceiving critical factors in the environment
Blood pressure values in a progress note
Understanding what those factors mean
Differential diagnosis integrating HX, PE and BP
Understanding what will happen within the system
next
Postoperative internal bleeding and ordering
serial blood pressure measurements
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The role of goals and goal-directed processing
when perceiving critical factors
Expectations directing perceiving and
understanding of critical factors
Expectation directed processing is distinct from
goal-directed
Expectations are generated by the situation
and forward looking.
Goals are what is wanted out of the whole
system
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There are two kinds of processing or
information:
Deliberate, effortful using working memory and
attentional effort
Pattern recognition with less effort and
awareness of the person , more about the
process of the diagnosis
Feedback – from humans, equipment; can be
immediate or delayed
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http://www.youtube.com/watch?v=xTkXJrNL7L
o&feature=related
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http://www.youtube.com/watch?v=vJG698U2M
vo
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http://www.youtube.com/watch?v=gZpG1j9qatY
&feature=related
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A person does not perceive a large or salient
object due to a combination of low expectation
and high mental workload
Involuntary
Misleading term – person is actually paying
attention but seemingly missing a salient object
May perceive partial aspects of the unexpected
object and use their expectations to fill in the
gaps and make it plausible, but inaccurate
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Can explain wrong medication dosage
Can explain a small instrument left at surgery
The resuscitation team missing the bright
Orange DNR instruction
The healthcare worker missing the bright
blinking light on the pump
Error in utilizing a simple device by mistaking
one symbol for another
ISMP Medication Safety alert 2009:14:1-2
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Conspicuity – how an object captures attention
– luminescence, contrast, shape
Mental workload and task interference –
distractions while doing a difficult task
Expectation of where something is located or
what it looks like is a strong effect – choosing
drugs from a cabinet
Confusion of the presence of other data –
computer screen or listing of information
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Discontinuity is an unfortunate reality of
hospital care
This discontinuity creates opportunities for
error or inaccuracy when data are transferred
Resident work hours have increase
discontinuity and the number of handoffs
Medication reconciliation
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A dministrative data must be accurate
N ew clinical information must be updated
T asks for the covering provider must be clearly
explained
I llness severity must be communicated
C ontingency plans for changes in clinical
status must be outlined, to assist crosscoverage in managing the patient overnight
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Interactive communications
Up to date and accurate information
Limited interruptions
A process of verification
An opportunity to review any relevant historical
data
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Preoperative
38%
Intraoperative
30%
Postoperative period
32%
Verbal communications occurred in 92% of
cases
64% were 1:1 communications
Status asymmetry was present in 74% of cases
Ambiguity about responsibilities in 73%
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Clearly establish who is responsible and make it
easy to reach that person and have a back up plan
Assign patient care tasks and responsibilities to
providers in a clear and unambiguous manner
Designate one patient care team as the primary
team. This team writes and confirms all orders
Routinize the sign out procedure, including a
designated time and place. It should take priority
over all activities except emergencies
Include in handoff lists patients expected to come
under or be released from the care of the team
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Read back verbal orders or test verification
Face to face exchanges are preferred as it allows
real time questioning and confirming as well as
nonverbal communication cues to be exchanged
Computerized medical record to reduce illegibility
for a written communication to augment the verbal
handoff
Signout should include: key demographics, short
history and PE, active problem list, meds and
allergies, pending test results, anticipated therapy;
code status disposition issues
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Reduce complexity through conscious effort
and preplanning
Standardization is important
Load leveling strategies – explicit job
assignments
Make known hidden events and activities (
visual displays of current status and detailed
view)
Focus attention toward the most unstable
patients or processes
Wrong patient, wrong body part, wrong side of the
body, wrong level of the anatomical site
Multiple surgeons
Multiple procedures
Unusual time pressures
Unusual physical characteristics - Obesity,
Deformity
Relying on imaging studies
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Meaningful dialogue with patients
Literacy allows patients to have the ability to
make appropriate health decisions
Break down cultural barriers
Obtain a list of patient medications plus
vitamins, herbal and natural supplements
Clear instructions on why the medication is
given, how much, and how it is administered
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Expert vs. Novice
Hierachical
Culture/ethnicity/language differences
Gender
Socioeconomics
History of unresolved conflict
Personality/behavior of the patient or provider
Level of respect
Tone of voice
Body Language
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1) Safe – avoiding injury to patients
2) Effective – Providing services based upon
scientific knowledge ( avoid over and under
use)
3) Patient – centered – respectful and
responsive to patient values
4) Timely – reducing waits and harmful delays
to those who receive and give care
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5) Efficient – avoid waste of equipment,
supplies, ideas and energy
6) providing care that does not vary in quality
because of personal characteristics such as
gender, geographic location and
socioeconomic status
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Removed from the direct control of the operator
Poor design
Incorrect installation
Faulty Maintenance
Bad Management decisions
Workload volumes
Poorly structured organization
Latent errors precede and/or are coincident
with every medical accident
RISK MANAGEMENT
Procedures
Drugs
Teamwork and
communications
QUALITY
INIDICATORS
Cases for Peer
review
ACOG standards
IHI Adverse events
LEVEL OF
MEASUREMENT
Hospital, Medical
Group, Provider,
Population
OVERSIGHT
Sentinel Event
Alphabet soup
PROCESS
MEASURES
Antibiotics VTE
prevention
Antenatal steroids
C/S in < 30 min
NO HARM EVENT
Near Miss analyses
OUTCOME
MEASURES
Mortality
Severe Morbidity
Injuries
LEVEL OF
RELEASE
Public, Confidential,
Internal
benchmarking
OTHER
MEASURES
Utilization
review ( over
and under)
Access
Disparity
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PATIENTS ARE NOT
SOCIAL SECURITY NUMBERS
MEDICAL RECORD NUMBERS
ACCESSION NUMBERS
ROOM NUMBERS
INITIALS
PATIENTS ARE TITLE LAST NAME
FIRST NAME
NICK NAME
PET NAME
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ADAPTIVE Unconscious
Rapid cognition – thin slicing
Telegraph Operator’s fist
Grasping the entire field at once
Chart notes ignoring others’ contributions
If some is good more is better
Momentary autism and split second syndrome
“Staying the course”
Zebras and Black Swans
When a new technique is so very innovative that
no other surgeon at your hospital has more
experience it is wise to arrange for extra
support staff or surgical backup to be available
should difficulties arise. The surgeon involved
should have already documented skills and
experience in the surgical arena and should
have solicited and received the advice and
support of other experienced surgeons
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All members of the surgical team must be trained
on and practice with the new equipment as
appropriate for the extent of their involvement,
and all personnel involved must b aware of all
safety features, warnings, and alarms of the
device. The institution’s medical engineering
department should inspect the equipment and
verify that it is functioning properly before the
equipment is put into clinical use. Stickers
attached to the device or plastic cards
summarizing instructions for proper use may be
helpful for everyone’s use of the equipment
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Normal contraction frequency is less than or equal
to 5 contractions in a 10 minutes window averaged
over 30 minutes
Tachysystole – frequency in excess of normal
Application – spontaneous and induced
contractions
Abandoned terms – hyperstimulation and
hypercontractility
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Fetal Oxygenation involves the transfer of
oxygen from the environment to the fetus and
the fetal physiologic response if oxygen
transfer is interrupted.
The greatest strength of EFM is its ability to
predict the absence of metabolic acidemia and
hypoxic neurologic injury with an extremely
high degree of reliability
Its greatest weakness is its inability to predict
the presence of these conditions with any
clinical accuracy
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All clinically significant FHR decelerations
reflect interruptions of the pathway of oxygen
transfer at one or more points
The pathway form normal to hypoxemia is a
series of sequential physiological steps
Moderate variability and/or accelerations
reliably predict the absence of fetal metabolic
acidemia
Acute interruption of fetal oxygenation does not
result in neurological injury in the absence of
significant metabolic acidemia
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Confirm FHR and UA: minimize sources of
preventable error May need to change from
external to internal monitoring techniques
Evaluate 5 components; baseline rate; variability;
accelerations; decelerations; and changes in
trends over time
Assess q 30 min first stage and q 15 min in 2nd
stage. In HR patients 15 and 5 minutes
Other than category 1 tracings practice ABCD
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Assess
Begin Corrections
Clear obstacles to rapid delivery
Determine decision to delivery time
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If tracing not Cat 1 assess the oxygen pathway
and consider other causes of FHR changes
Interruption of the oxygen pathway should be
addressed with appropriate conservative
corrective measures
If Cat II additional evaluation
If Cat III consider expedited delivery
Use a checklist to organize sources of potential
delays and deal with them
Delivery
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Teamwork training – Team and Individual
training, Simulations, Protocol development,
Guidelines, checklists, Information technology,
education of personnel and patients
Training Methods – Communication; Situation
Monitoring, Mutual support, Leadership
TEAMstepps.ahrq.gov
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HTTP:
//WWW.
FDA.GOV.
WOMENS/
REGISTRIES
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VTE is leading cause of maternal death 1:1000
pregnancies
1/3 to ½ of VTE occurs postpartum
Cesarean increases VTE risk for emergency
C/S; Obesity; age.35 years; Thrombophilia;
smoking; Preeclampsia; and Multiple gestation
ACOG – IPC devices are worthwhile; early
ambulation. Chemoprophylaxis for specific risk
factors
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Requires that residency programs maintain
formal educational programs in handoffs and
care transitions
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Critiques of resident teaching and care are:
Blurred boundaries of responsibilities
Decreased surgeon familiarity with patients
Diversion of surgeon attention
Distorted or inhibited communications
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Transformational – Broad view of safety for the
entire organization. Charismatic and
empathetic. Will articulate goals and allow
others to complete tasks. This style improves
employee satisfaction.
Transactional – clear goals for compliance form
others. Is hierarchical producing reliable and
predictable outcomes
Laissez faire – abdicates role and will not help[
promote the new culture
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Outpatient – Lidocaine; Monsel’s
solution; Trichloroacetic acid;
vaccinations; conscious sedation
Labor and delivery Triage – IV fluids;
antiemetics; narcotics; asthma
therapies; sleep aids; etc.
 Obtaining medication from unit stock
instead of the pharmacy removes one layer
of check on the medication.
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Collaboration and mutual respect
Job Satisfaction
Role of leadership in support of individual
performance
Staffing and work load
Impact of stress and fatigue
Effective communication
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www.utpatientsafety.org
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Patient Safety Climate
Shorten length of hospital stay
Fewer medication errors
Lower rate of ventilator-associated
pneumonia
Lower blood stream infections
Lower risk-adjusted mortality
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OXYTOCIN
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MAGNESIUM SULFATE
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PROSTAGLANDINS
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OPIODS
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HEPARIN
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Computerized Physician Order entry
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Bar code Medication
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Smart Infusion pumps
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Patient education regarding home meds and
herbals and medication reconciliation
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Individualized therapy based upon the patient’s
stratified risk
We don’t know enough about patients and
should treat everyone undergoing major
gynecological surgery
Arguments about what constitutes major gyn
surgery
Compression devices reduce DVT rates if
maintained for 5 days (34% vs. 12%)
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Evidence based – higher incidence of DVT
in patients undergoing GYN surgery ( 1040%)
 Embolism rates high in gyn malignancies
(5-10%)
 Embolism rates in gyn malignancies with
VTE prophlyaxis (1-4%)
 5 fold increase in VTE risk with pregnancy
Not Evidence based – antithrombotic
medicines and mechanisms decrease
DVT and PE in OB GYN patients
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THE VISIBLE WAY FOR THE PHYSICIAN
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AND THE TEAM
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TO PROVIDE REDUNDENCY AND
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CONSISTANCY TO KEY ITEMS
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MAINTAINS SITUATIONAL AWARENESS