On the CUSP: STOP BSI
The Science of Improving Patient Safety
© 2009
Immersion Call Overview
Week 1: Project overview
Week 2: Science of Improving Patient Safety
Week 3: Eliminating CLABSI
Week 4: The Comprehensive Unit-Based Safety
Program (CUSP)
Week 5: Building a Team
Week 6: Physician Engagement
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Learning Objectives
• To recognize that every system is designed to
achieve the results it gets
• To identify the basic principles of safe design that
apply to both technical and team work
• To discuss how teams make wise decisions
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The Marvel of Modern Medicine
© 2009
RAND Study Confirms Continued Quality Gap
Condition
% of Recommended Care Received
Low back pain
68.5
Coronary artery disease
68.0
Hypertension
64.7
Depression
57.7
Orthopedic conditions
57.2
Colorectal cancer
53.9
Asthma
53.5
Benign prostatic hyperplasia
53.0
Hyperlipidemia
48.6
Diabetes mellitus
45.4
Headaches
45.2
Urinary tract infection
40.7
Hip fracture
22.8
Alcohol dependence
10.5
1. McGlynn EA, Asch SM, Adams J, et al., N Engl J Med, 2003.
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The Problem is Large
• In U.S. Healthcare system
– 7% of patients suffer a medication error 2
– On average, every patient admitted to an ICU suffers an adverse event
– 44,000- 98,000 people die in hospitals each year as the result of medical
errors 5
– Nearly 100,000 deaths from HAIs 6
– Estimated 30,000 to 62,000 deaths from CLABSIs 7
– Cost of HAIs is $28-33 billion 7
• 8 countries report similar findings to the U.S.
2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995
3. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.
4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.
5. Kohn L, Corrigan J, Donaldson M., To Err Is Human, 1999.
6. Klevens M, Edwards J, Richards C, et al., PHR, 2007
7. Ending Health Care-Associated Infections, AHRQ, 2009.
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3,4
How Can These Errors
Happen?
• People are fallible
• Medicine is still treated as an art, not
science
• Need to view the delivery of healthcare as a
science
• Need systems that catch mistakes before
they reach the patient
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Understanding the Science of
Safety
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How Can We Improve?
Understand the Science of Safety
• Every system is perfectly designed to achieve the results it gets
• Understand principles of safe design
– standardize, create checklists, learn when things go wrong
• Recognize these principles apply to technical and team work
• Teams make wise decisions when there is diverse and
independent input
Caregivers are not to blame
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System Failure Leading to This Error
Communication between
resident and nurse
Inadequate training
and supervision
Catheter pulled with
Patient sitting
Patient suffers
Lack of protocol
For catheter removal
Venous air embolism
8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.
9. Reason J, Hobbs A., 2000.
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System Factors Impact Safety
Institutional
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
10. Adapted from Vincent C, TaylorAdams S, Stanhope N., BMJ, 1998.
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Evidence Regarding the Impact of ICU
Organization on Performance
• Physicians11
• Nurses12
• Pharmacists13
11. Pronovost P, Angus D, Dorman T, et al., JAMA, 2002.
12. Pronovost P, Dang D, Dorman T, et al., ECP, 2001.
13. Pronovost P, Jenckes M, Dorman T, et al., JAMA, 1999.
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Fatal Aviation Accidents per
Million Departures
14. Statistical Summary of Commercial Jet
Airplane Accidents, Aviation Safety
Boeing Commercial Airplanes, July 2009.
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Principles of Safe Design
• Standardize
– Eliminate steps if possible
• Create independent checks
• Learn when things go wrong
–
–
–
–
What happened
Why
What did you do to reduce risk
How do you know it worked
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Standardize
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Line Cart Contents – 4 Drawers
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Eliminate Steps
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Create Independent Checks
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2 Year Results from 103 ICUs
Time period
Median CRBSI rate
Incidence rate ratio
Baseline
2.7
1
Peri-intervention
1.6
0.76
0-3 months
0
0.62
4-6 months
0
0.56
7-9 months
0
0.47
10-12 months
0
0.42
13-15 months
0
0.37
16-18 months
0
0.34
15. Pronovost P, Needham D, Berenholtz S et al., N Engl J Med, 2006.
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Principles of Safe Design Apply to
Technical and Team Work
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Basic Components and Process of
Communication
16. Dayton E, Henriksen K, Jt Comm J Qual Patient Saf, 2007.
% of respondents reporting above adequate teamwork
ICU Physicians and ICU RN
Collaboration
17. ICUSRS Data from Needham D, Thompson D,
Holzmueller C, et al., Crit Care Med, 2004.
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Teamwork Tools
•
•
•
•
•
•
Staff Safety Assessment
Daily goals
AM briefing
Shadowing
Barrier Identification and Mitigation
Learning from Defects
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Systems
• Every system is designed to achieve the results it gets
• To improve performance we need to change systems
• Start with pilot test
 one patient, one day, one physician, one room
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Teams Make Wise Decisions When There is
Diverse and Independent Input
• Wisdom of Crowds
• Alternate between convergent and divergent
thinking
• Get from the dance floor to the balcony level
18. Heifetz R, Leadership Without Easy Answers,1994.
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Don’t Play Man Down
When you feel something say something
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Recap
• Develop lenses to see systems
• Work to standardize one process
• Infuse these principles of standardization and
independent checks in other processes
• Don’t play man down
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Action Items
• Have all members of the CUSP/CLABSI Team view
the Science of Improving Patient Safety video
• Put together a roster of who on your unit needs to
view the Science of Safety video
• Develop a plan to have all staff on your unit view
the Science of Improving Patient Safety video
– Assess what technologies you have available for staff to
view
– Identify times for viewing it (e.g., staff meetings, individual
admin hours)
© 2009
Works Consulted
1.
McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United
States. N Engl J Med. 2003;348 (26): 2635-45.
2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse
drug events. JAMA. 1995;274(1):29-34.
3. Donchin Y, Gopher D, Olin M, et al., A look into the nature and causes of human errors in the
intensive care unit. Crit Care Med. 23:294-300,1995.
4. Andrews LB, Stocking C, Krizek T, et al., An alternative strategy for studying adverse events in
medical care. Lancet. 349:309-313,1997.
5. Kohn L, Corrigan J, Donaldson M. To Err Is Human: Building a Safer Health System. Washington,
DC: National Acad Pr; 1999.
6. Klevens M, Edwards J, Richards C, et al., Estimating Health Care-Associated Infections and
Deaths in U.S. Hospitals, 2002. PHR.122:160-166,2007.
7. Ending Health Care-Associated Infections, AHRQ, Rockville,MD, 2009.
http://www.ahrq.gov/qual/haicusp.htm.
8. Pronovost P, Wu A, Sexton J, et al. Acute decompensation after removing a central line:
practical approaches to increasing safety in the intensive care unit. Ann Int Med.
2004;140(12):1025-1033.
9. Reason J, Hobbs A. Managing the risks of organizational accidents. Burlington, VT: Ashgate
Publishing Company, 2000.
10. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical
medicine. BMJ. 1998; 316: 1154–7.
11. Pronovost P, Angus D, et al. Physician staffing patterns and clinical outcomes in critically ill
patients: a systematic review. JAMA. 2002;288(17):2151-2162.
12. Pronovost P, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for
complications after abdominal aortic surgery. Effective clinical practice: ECP. 2001;4(5):199206.
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Works Consulted
13. Pronovost P, Jenckes M, Dorman T, et al. Organizational characteristics of intensive care units
related to outcomes of abdominal aortic surgery. JAMA. 1999;281(14):1310–7.
14. Statistical Summary of Commercial Jet Airplane Accidents: Worldwide Operations 1959-2008.
Boeing News Releases/Statements. July 2009. Aviation Safety Boeing Commercial Airplanes,
Web. 21 Jan 2010. <www.boeing.com/news/techissues/pdf/statsum.pdf>.
15. Pronovost P, Needham D, Berenholtz S et al. An intervention to decrease catheter-related
bloodstream infections in the ICU. New Engl J Med. 2006;355(26):2725-32.
16. Dayton E, Henriksen K. Communication Failure: Basic components, contributing factors, and the
call for structure. Jt Comm J Qual Patient Saf. 2007; 33(1): 34-47.
17. Needham D, Thompson D, Holzmueller C, et al. A system factors analysis of airway events from
the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004;32:2227-33.
18. Heifetz R, Leadership Without Easy Answers, President and Fellows of Harvard College,1994.
© 2009