“Teaching, Learning and
Keeping Everyone Safe:
All at the Same Time”
Stephen E. Muething, MD
ECT Faculty Recognition Dinner Keynote
September 21, 2011
UNITED STATES
60,000 – 100,000 deaths per year from
adverse events in hospitals
OHIO
•
•
•
•
60,000 Experience adverse events annually
50,000 years of potential life lost
1 Billion dollars in direct healthcare expense
5% of nosocomial infections lead to death:
7,500 deaths each year
• 6.5% of patient admissions results in a
adverse drug event
CHILDREN
• 1 Billion dollars annually secondary to
patient safety issues
• Surgical Site Infections: increase stay of 10
days
• Blood Stream Infections: increase costs of
$33,000 each
• Ventilator-associated Pneumonias: increase
stay of 8 days
Check Lists
Leadership
“Wash Your Hands”
RELIABILITY
CONTROVERSIAL STATEMENT #1
STANDARDIZATION
Helps our Learners Learn
• “STANDARDIZATION IMPARES LEARNING”
• “I LEARNED FROM OBSERVING”
• “IT’S A COOKBOOK”
RELIABILITY CULTURE
HIGH RELIABILITY ORGANIZATIONS
Others have been Implementing,
Learning and Improving for decades
MINDFULNESS
COMMONALITIES of HRO’s
• Unforgiving social and political environment
• Environment rich with potential for error
• Scale of consequences precludes learning
through experimentation
• Complex processes
• Complex technology
-Rochlin, 1993
CORE CHARACTERISTICS
• Preoccupation with Failure
- Encourage reporting of even small errors and convene quickly
to address
• Reluctance to Simplify Interpretations
- Encouraging diversity in experience, perspective, and
opinion
• Commitment to Resilience
- “errors don’t disable”
• Deference to Expertise
- Decision making deferred to workers with the most
knowledge and expertise not the highest rank
• Sensitivity to Operations
- Find loopholes in system’s defenses, barriers and
safeguards on the frontline. Maintain Situation Awareness
HROs and Hospitals
• Preoccupation with Failure
– Near misses are viewed as invitations to
improve, not successes
– Chronic unease/wariness instead of
complacency
– “No Blame” culture
– Everyone discusses every day what “almost
happened”
HROs and Hospitals
• Reluctance to Simplify Interpretations
– Don’t assume failures are the results of a
single, simple cause
– Understand all the ways the system may fail
– Look to others who may do things better
– Use cause analysis to plan improvements
HROs and Hospitals
• Commitment to Resilience
– Assume errors will occur
– Lookout for the unexpected and the unusual
– All should be aware when the system is in a
stressed situation
– Practice, practice for the “unexpected”
– Simulation training
HROs and Hospitals
• Deference to Expertise
- Front-line leaders are empowered to solve
problems everyday and escalate more complex
issues right away
– Staff at every level are comfortable sharing
information and concerns and finding solutions
– Includes the patient as well as the family
HROs and Hospitals
• Sensitivity to Operations
– Organization designed around the front-line
not the other way around.
– Safety behaviors are clear
– Daily and Shift Huddles
– 200% accountability
– Situation Awareness
CONTROVERSIAL STATEMENT #2
If you’re not building situation awareness
you’re setting learners up for failure
WHAT IS SITUATION AWARENESS?
Situation Awareness Model
Family
concerns
High risk
therapies
Bedside
Team
Microsystem
Team
Organization
Team
Intern
Watchstander
Senior Resident
MRT
Bedside
nurse
Watchstander
PCF/Manager
Safety Team
(MPS and SOD)
at 800, 1600 & 100
PEWS>5
Watcher
Reliable escalation of risk
Communication
concern
Attending
Rapid assessment and
communication with
primary team
32
Are we an HRO Yet?
Not Yet!
CONTROVERSIAL STATEMENT #3
We CAN eliminate preventable serious harm
from teaching hospitals
CONFIDENTIAL
This document is part of the quality assessment activities of Cincinnati Children’s Hospital Medical Center and, as such, is a confidential document not subject to discovery pursuant to
Ohio Revised Code (ORC) Sections 2305.24, 2305.25, and 2305.252. All committees involved in the review of this document, as well as those individuals preparing and submitting
information to such committees, claim all privileges and protection afforded by ORC Sections 2305.24, 2305.25, 2305.251, and 2305.252 and any subsequent legislation. The information
contained is solely for the use of the individual or entity intended. If you are not the intended recipient, be aware that any disclosure, copying, distribution, or use of the contents of this
document is prohibited.
# of Events
Hospitals
01/10
02/10
03/10
04/10
05/10
06/10
07/10
08/10
09/10
10/10
11/10
12/10
01/11
02/11
03/11
04/11
05/11
06/11
07/11
45
58
74
46
57
57
48
67
42
50
37
30
52
42
56
52
43
44
40
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
7
Serous Harm Index: VAP, BSI, UTI, Serious Falls, High Risk SSI Cases, ADE(6-9), PU (3-4), Codes and SSE's
All Harm Index: All items above PLUS .... ADE(5), PU(2), PIV (2-4), any other SSI from other Surgical Areas
This document is part of the quality assessment activities of OhioChildren’s Hospitals Solutions for Patient Safety Learning Network and, as such,it is a
confidential document not subject to discovery pursuant to Ohio RevisedCode Section 2305.25, 2305.251, 2305.252, and 2305.253. Any committees
involvedin the review of this document, as well as those individuals preparing andsubmitting information to such committees, claim all privileges and
protectionafforded by ORC Sections 2305.25, 2305.251, 2305.252, 2305.253 and 2305.28 andany subsequent legislation. The information contained is
solely for the use ofthe individuals or entity intended. If you are not the intended recipient, beaware that any disclosure, copying, distribution or use of
the contents of this information are prohibited.
HUMAN FACTORS
• Designing technology that makes it difficult
to make errors
• Understanding decision making and
designing health record to facilitate decisions
• Learn what makes a high performance team
and replicate
• QUESTIONS?
• COMMENTS?
• CONTROVERSIAL STATEMENTS
WELCOME!
Thank you