Grand Rounds
Thursday, February 28, 2013
Patient Safety – No Problem Here
 http://www.youtube.com/watch?
v=hJbYwL2vfJE
 Silent Killer , Josie King Story
Answer = Zero
The correct question is:
 Mizzou’s trips to the Final Four?
 The number of children harmed in our
MRI?
 CMH’s strategic plan harm goal?
 The chance that nobody in the Auditorium
or off site spots isn’t currently on their
smart phone or tablet?
2017 Goals and Strategies
Demonstrate Quality
Outcomes
Demonstrate Quality
Outcomes
Goals
Demonstrate Quality
Outcomes
B1. Effectively allocate
staffing and other
resources to meet needs
Strategies
A1. Eliminate harm
A2. Improve the
outcomes of the care
provided
B2. Increase transparency
and accountability
B3. Build upon a culture
which is agile/nimble and
engaged in innovation at
all levels
B4. Enhance team
behaviors to promote
service excellence for
internal & external
customers
C1. Assertively act to
retain current regional
position and take
proactive steps to secure
and grow complex
patient referrals in
Southwest Missouri and
Eastern Kansas
C2. Grow inpatient and
specialty outpatient
services at CM-South
C3. Improve the
relationship with and
connection to primary
care physicians
C4. Enhance access across
our system
D1. Enhance and grow
the Pediatric Care
Network (PCN)
D2. Work with
commercial payers
and/or adult Accountable
Care Organizations to be
their pediatric network
D3. Leverage system
expertise to build
business opportunities
outside of traditional
market areas (e.g.,
international)
E1. Enhance the research
enterprise with cohesive
oversight/ guidance,
broad-based funding,
and a focused research
portfolio
E2. Increase the caliber
of CMH’s educational
programs ensuring
leading-edge teaching
approaches
Answer = Ten
What is the best question:
 Years since I completed my residency?
 Number of HACs being tracked by the
Children’s Hospitals Solution for Patient
Safety Consortium?
 Number of central line infections (CLABSIs) at CMH last year?
 Mike Artman’s golf handicap?
Safety Event Classification
Precursor Safety Event
Near Miss Safety Event
Near Miss Safety Event
 Does not reach the patient.
 Error found by detection barrier
or luck.
 http://www.youtube.com/watch?
v=KNqWPswYYaA
 Amazing near miss car crash
Precursor Safety Event
 Reaches the patient.
 Minimal or no detectable harm.
 http://www.youtube.com/watch?
v=CKkXQxQyYpU
 4 yr old Turkish Boy's Amazing
Escape
Serious Safety Event
 Reaches the patient.
 Causes moderate or severe
harm,
 Or causes death.
 http://www.youtube.com/watch?
v=RPBlEE3xIE0
 A closer look at a medication error
Answer = Too numerous to count
What is the best question:
 Days since Burry retired?
 Near miss safety events in our MRI?
 Surgical site infections in the past
academic year?
 Losses by the KU football team in past
10 years?
 http://www.youtube.com/watch?
v=plvIEf7JsKo
 Dangers of MRI
Answer = Four
What is the best question:
 Number of times Jason Newland has
competed in the Hawaii Ironman?
 Number of people who have given
Jason a hard time this week?
 Number of near miss wrong site
surgery events since Jason has been
the Medical Director of Safety?
 http://www.youtube.com/watch?
v=SxDx2DlL0UY
 Tom Shillue's Wrong Side Surgery
 http://www.youtube.com/watch?
v=t6mr3gxXx64
 Jess’s story
Jess’s Story
“The Holter monitor test was
never looked at until after I died,
more than a year after I had the
test.”
“Zero”
2012 PICU Quality Improvement
Report
Chris Hubble, MD
Kathy Baharaeen, RN
2012 PICU Quality Improvement
Report
 CLA-BSI
Total Number
Total CVL days
Rate
 36% reduction
2012
15
5611
2.67/1000 days
2011
23
5484
4.19/1000 days
2012 PICU Quality Improvement
Report
Unplanned Extubations
Totals
2012
12
2011
38
2012 PICU Quality Improvement
Report
PICU – Catheter Associated UTIs (CA-UTI)
Nurse driven removal algorithm
 Rate before algorithm (July – Dec 2011) = 5.83
 Rate after algorithm (July – Dec 2012) = 2.24
 60% reduction
2012 PICU Quality Improvement
Report
2012
2011
Total Patient Days
8154
7885
Deaths
45
65
 patient mix equal
 20 lives saved
 http://www.youtube.com/watch?
feature=player_embedded&v=G
POQ8pzY0kY
 Labels Out