Casting the Safety Net –
Fish or Cut Bait?
Capturing Precursor Safety Events
Indiana Association for Healthcare Quality
2010 Annual Conference
April 30, 2010
Martha Boutin White, RN, BSN, MBA,
Patient Safety Officer
Memorial University Medical Center
Savannah, GA
Sherry L. Sweek, RHIA, CPHQ, CPMSM,
Director of Quality Improvement
Southeast Georgia Health System
Brunswick, GA
Objectives
• Define Precursor Safety Events including
errors of omission
• Explain leverage points introduced to
increase reporting and decrease errors
• Share results and data analysis
• Review lessons learned
• Discuss next steps and recommendations
Overview
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Memorial’s safety journey
2008 Safety refocus
Precursor safety events project
How we got started
Problems we encountered
Current safety performance
Next steps
Memorial University Medical Center
• Two-state healthcare organization servicing a
35-county area in southeast Georgia and
southern South Carolina
• Four-year medical school on campus affiliated
with Mercer University School of Medicine
• 530-bed tertiary hospital with Core Services:
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Level 1 Trauma Center
Level 3 Neonatal Intensive Care Nursery
Heart & Vascular Institute
Curtis & Elizabeth Anderson Cancer Institute
George & Marie Backus Children’s Hospital
Rehabilitation Institute
Off Course: An Alarming Trend in 2002
Overall (Near Miss + Sentinel Event)Trend
Actual
# of Events
Best-fit Trendline
1998
1999
2000
2001
2002
2003
2004
Gaining Direction in Our Safety Journey
• Conducted Mandatory Error Prevention Training (Team
Members, Team Leaders and Physicians)
• Enhanced Analysis of Events (Root Cause / Common
Cause)
• Established and Enforced “RED Rules” for Operating
Room, Invasive Procedures, and overall Hospital Global
“RED Rules”
• Implemented Incident Scoring System (Compliance &
Patient Outcome)
• Incorporated Increased Reporting Metric (ROSI) in Team
Leader Bonus Structure
• Created Safety Coach Program and Dedicated FTE
Positions
We Thought We Had
The Right Course
Straying Off Course: 2006-2007
• Dealt with OIG Investigation for Alleged Stark Violations
and 22 surveys in an 18 month time period
• Observed 31% Decreased Incident Reporting
• Discounted Increased Sentinel Events Due to Joint
Commission Definition Changes
• Failed to Recognize System Wide Issues and Implement
Changes
• Experienced Instability with Loss of Patient Safety Officer,
COO, CNO, CFO, Director of Quality, VP of Quality and
Patient Safety
• Moved Away from Safety to Financial Situations by All
Leaders
• Not Cognizant of the Impact of Financial Woes on Safety
MUMC Organizational Complacency
Memorial Health SSE Rate 2002 to January 2008
Create a Safe
Day
Stage 5: Collapse
SSE Rate
Stage 4: Denial
Stage 3: Blindness
Stage 1:Good Operations
Stage 2: Self Satisfaction
Jan 02 May 02 Sep 02 Jan 03 May 03 Sep 03 Jan 04
May 04 Sep 04 Jan 05 May 05 Sep 05 Jan 06 May 06 Sep 06 Jan 07
May07
Sep 07 Jan 08
When Did We Fish?
Dec 2007
Nov 2007
Oct 2007
Sep 2007
Aug 2007
Jul 2007
Jun 2007
May 2007
Apr 2007
Mar 2007
Feb 2007
Jan 2007
Dec 2006
Nov 2006
Oct 2006
Sep 2006
Aug 2006
Jul 2006
Jun 2006
May 2006
Apr 2006
Mar 2006
Feb 2006
Jan 2006
Dec 2005
Nov 2005
Oct 2005
Sep 2005
Aug 2005
Jul 2005
Jun 2005
May 2005
Apr 2005
0.90
Mar 2005
Feb 2005
Jan 2005
SSE Rate
1.00
Serious Safety Event Rate (SSER) for MUMC
2005 - Present per adjusted 10,000 patient days
Serious Safety Events
Serious Safety Event Rate for MUMC
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
Total Time to Complete
a Root Cause Analysis
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Determination of SSE – 6–8 hours (x2)
Communicating to stakeholders - 6
Charter – 1 hour
Interviews – 1 hour each (x10x3)
Swiss Cheese diagram – 1 hours
Task Analysis – 3 hours
Event Time Line – 2 hours (x2)
Team Meetings – 2.5 hours each (x8x3)
Report Completion – 2 hours
Pre-report with Champion – 1 hour (x3)
Presentation of Report – 1.5 hours (x4)
Coding the event in database – 1 hour
Total: 133 hours/month
“We’re gonna know all there is to
know about the PSE business”
SEC
Serious Safety Event
Variation in standard of care
Reaches the patient
Death or major harm
Cause Analysis Level: RCA
Precursor Safety Event
Variation in standard of care
Reaches the patient
Minimal or no harm
Cause Analysis Level: ACA
Serious
Safety
Events
Precursor
Safety
Events
Near Miss
Variation in standard of care
Does not reach the patient
Cause Analysis Level: Trend, ACA
Near Miss
SM
Safety
Event
Classification
What is a Precursor Safety Event?
• A precursor safety
event is a variation
in care that reaches
the patient but does
not cause
permanent harm
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Delay in treatment
Failure to recognize
Improper Pt ID
Inadequate check
Inadequate handoff
Inadequate monitoring
Missed medication
Missed treatment
Omitted Action
Wrong dose
Wrong medication given
Wrong treatment
Redirecting the Focus to Prevention
Nurse skips chart check
Pharmacist
enters
wrong dose
Pharmacy
Tech fills order
PSE
SSE
Physician
writes
ambiguous
order
NM
NM
NM
Barriers to Harm
Nurse administers 10X dose
(medication overdose)
Did We Have the Right Equipment?
• License – Approval of Quality & Patient
Safety Committee and Board of Directors
to fish for PSEs
• Net – Decree to increasing the number of
incident reports became a strategic
objective
• Bait – Rewards for Safety Saves
• Catch – Precursor Safety Events with
coded information to drive improvement
We Bought a Trawler...on Credit
We Pulled Up Full Nets
• 2009: 8,509 incidents, 2 Serious Safety
Events
– 709 incidents per month
– 210 incidents per month visitor issues,
workers comp or physician complaints
– 144 incidents per month near misses
– 355 PSEs per month
• Everyone gets to eat….
Beware of Shifting Tides
• Fishy Headlines
– Paradigm Shift Required
– Risk Management Shares Information and
Promotes Transparency
– No Compass on How to Navigate
– Internal Sonar Better Than Nothing
Risk Throws in a Flotation Device
• Began Weekly Meeting with Risk
– Review Precursor Safety Events
– Verify Profession Involved
– Define Inappropriate Act
– Determine Apparent Cause Reports
– Code Completed A/C reports
– Review Safety Saves for PSEs
Back on Dry Land…
• Assign Apparent Cause Reports in Safety
Database
• Have Management Engineers Customize
Database to House PSE information
• Compile Safety Saves and Produce
Certificates
What’s Our Catch?
Is It a Keeper?
• WHEN I HAD FINISHED, I BROUGHT pt.
N WAS NO LONGER WITH PT AND PT
WAS NOT MONITORED. PT INITIALLY
CAME TO ER FOR TRAUMA TO
FACE/HEAD FROM FALL. PT WAS NOT
AWAKE, OR COMMUNICATIVE WITH ME
WHEN I BROUGHT HER TO THE
SCANNER. I WAS ABOUT TO GET
ASSISTANCE WITH MOVING THE PT
WHEN SHE coded
We Fish, They Feast
• Generated Department Specific PSE
Report
• Included PSE Reports to Senior Leadership
Rounds
• Send PSE Reports to Managers, Directors
and Safety Coaches
• Modified PSE Report Format to Incorporate
Voice of Customer
Man Overboard!!!
• Hard to Stay the Course When Everyone
Wants to Change Direction
• Teach Them to Fish, Teach Them to Fish,
Teach Them to Fish
• Safety Drills
– Swiss Cheese of Errors
– Reinforce Error Prevention Techniques
– Required Actions from Senior Leadership,
Directors, Managers
I Caught a Fish This BIG…
• Added PSE to Monthly Dashboard
• Established Procedure for Accountability for
Apparent Causes Completion
• Determined Frequency of PSE Report to
Quality Oversight Committee and Board of
Directors
• Conducted and Presented Common Cause
Analysis Based on PSE Data
My Fish is Bigger Than That
• Safety Rounding Tool Modified Each
Month Based on Data from PSEs
– STAR (Stop, think, act, review)
– Safety Huddles
– Patient Identification
• Pre Rounding Huddle for Unit Specific
Trend or Unresolved Issues
• Behavior Based Monitoring Compliance
Included on Report and in Dashboard
We Confirm Tears in The Nets
Looking First for Tears in The Net
• Included data from October 2008 through May 2009
• Data used to generate reports for Patient Safety
Rounds
• 734 Precursor Safety Events
– 869 Inappropriate Acts
– Majority of Inappropriate Acts are committed by “Sharp
End” care givers
• All PSE’s coded based on event description and
additional investigation emphasizing coding data
from:
– Apparent Cause Reports
– Level 1 or Level 2 PSEs (temporary or minor harm)
• 70% of PSEs only partially coded due to incomplete
information
% of PSEs Related to Medical Errors
100%
% of Errors
80%
62.50%
60%
45.90%
40.32%
40%
37.50% 36.47%
27.40%
22.43%
42.68%
33.33%
34.12%
18.75%
20%
0%
Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09
Month
Comparison of Medication Errors to Medication Safety Saves
Errors
Safety Saves
40
20
35
18
Data & A/C
# of Errors
30
16
Approval for
6 mth study
14
PSE Report
& Rewards
25
MAXPI
20
Saves
& MAX
Blitz
12
10
8
15
6
10
4
5
2
0
0
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Month
Apr-09
May-09
Jun-09
Jul-09
Aug-09
# of Safety Saves
Mine Data
A/C reports
“PSEs are like a
box of chocolates.
You never know
what you’re gonna
get….”
The Radar Suggests…
• Sharp End Employees are Identified Most
Often in Committing Inappropriate Acts
– RNs, Pharmacists and Physicians
• Common Threads Among all Professional
groups
– S.T.A.R. (Stop, Think, Act, and Review)
– Rule Based Errors (Patient ID Error)
• Limitations of The Data
– Self-reported
– Incomplete Data
– Some Areas Still Perceive Reporting as Punitive
EPTs All Professional Groups
400
350
300
250
200
150
100
50
0
S.T.A.R. - Stop, Check Each Other
Think, Act, Review
STOP when
Unsure
Adhere to Red
Rules and policies
Use SBAR,
Ask Two Clarifying Coach Each Other
SHARED
Questions
using "ARCC"
Communication
Methods
Read Back and
Verify
Inappropriate Acts
140
120
100
80
60
40
20
0
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
Inappropriate Acts if S.T.A.R. Utilized
140
120
100
80
60
40
20
0
Oct-08
Nov-08
Dec-08
Jan-09
Feb-09
Mar-09
Apr-09
May-09
STAR as an Effective Error Prevention Tool – High
Risk Areas
Unit
Inappro.
Acts
S.T.A.R.
% of PSE's that could be
prevented using S.T.A.R.
Pharmacy
ED
NICN
PEDS
67
44
39
32
43
15
21
15
64.2%
34.1%
53.8%
46.9%
L&D
OR
NICU
27
19
6
4
12
2
14.8%
63.1%
33.3%
TOTAL
234
112
47.9%
•Above represent the units that have most frequent rounds
•L&D EPT Stop When Unsure could have prevented 9
additional PSE’s
Mending the Nets
Charting the Course
• Formed Two Ad-Hoc Teams on:
– Integrating S.T.A.R. into Patient Safety
Practice
– Maximizing Report Quality in MAXPI
• Team Initiatives Included on Top Ten List
• Team Skippers were CNO and CFO
• Development Center – Team Facilitation
• Team Recommendation
to Quality Oversight
Committee with
Implementation Plan
Stay Within the Bouys
• Added Precursor Safety Events Goals to
Safety Improvement Plan
• Included PSE Metrics on Monthly Dashboard
• Reported PSE Trends Quarterly to Quality
Oversight Committee and Board
• Conducted annual PSE
Common Cause Analysis
2009 Common Cause Navigation
• 1102 Precursor Safety Events
– 1310 Inappropriate Acts
– 17.5% of PSEs with Temporary or Minor Harm
– Results Mirror Common Cause from August
2009
– Five Straight Months with 100% of Apparent
Cause Reports Completed in Two Weeks
– 35%-45% of Inappropriate Acts are with
Medication Nutrition Process
– 50% of Inappropriate Acts could have been
Prevented by Using STAR
Precursor Safety Event Severity
% of PSE's rated a 1 or 2 (minimal or moderate temporary harm)
40.0%
35.0%
% 1 or 2 PSE
Linear (% 1 or 2 PSE)
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09
PSE Error Categories
Inapp. Acts
Knowledge Based
Rule Based
77, 7%
39, 4%
976, 89%
Skill Based
PSE Professional Group
Inappropriate Acts by Profession
900
800
786
700
600
500
400
300
200
96
95
100
71
55
36
31
30
25
28
15
Support
Misc
Clinical
Therapy
PCT
Tech - Rad
NonClinical
0
RN
Pharmacist
MD
Tech - Lab
HUC
PSE Error Prevention Techniques
EPTs All Professional Groups
600
500
400
300
200
100
0
S.T.A.R. - Stop, Check Each Other
Think, Act, Review
STOP when
Unsure
Adhere to Red
Rules and policies
Use SBAR,
SHARED
Communication
Methods
Ask Two Clarifying Coach Each Other
Questions
using "ARCC"
Nearly 50% of all inappropriate acts could have been prevented utilizing S.T.A.R.
Read Back and
Verify
S.T.A.R - RN
Key Processes - RN
400
350
300
250
200
150
100
50
0
Medication and Nutrition
Process
Coordinating Care
Patient Monitoring and
Assessment
Speciman Management
Admission Transfer
Discharge
Invasive Procedure
Utilizing STAR effectively could reduce 40% of inappropriate acts
related to the medication and nutrition process.
S.T.A.R - Pharmacy
Key Processes - Pharmacy
90
80
70
60
50
40
30
20
10
0
Medication and Nutrition Process
Coordinating Care
Utilizing STAR effectively could reduce 68% of inappropriate acts
related to the medication process.
S.T.A.R – M.D.’s
Key Processes - MD
35
30
25
20
15
10
5
0
Coordinating Care
Medication and Nutrition
Process
Invasive Procedure
Admission Transfer Discharge
Patient Monitoring and
Assessment
Utilizing STAR could reduce 29% of inappropriate acts. 9 of 33
Coordinating Care issues had to do with adhering to red rules.
Casting the Safety Net
• Obtaining Right Incident Information Up
Front a Challenge
• Identifying PSEs Easier Said than Done
• Moving Between Risk & Quality
Databases Cumbersome
• Preparing Leadership for the Number of
PSEs is Important
• Taking Action on PSE Data is Key to
Making Gains on Patient Safety
Our Goal: Catch Error
Before Patient Harm
• Let the data drive the improvements
• Apply concerted and focused effort
• Continue to raise the bar
Human Error
Serious
Safety
Event
Are We Catching Any Fish?
2007
2008
2009
AHRQ Patient Safety
Score
SSEs
Not
Collected
12
69%
77%
4
2
SSE Rate per 10,000
Adj. Patient Days
Avg. Days Between
Events
PSEs
0.45
0.18
0.08
37
73
182
Not
Collected
Not
Collected
1102
0.60
3
0.50
# SSE
0.80
2005
2005
2005
2005
2005
2005
2005
2005
2005
2005
2005
2005
2006
2006
2006
2006
2006
2006
2006
2006
2006
2006
2006
2006
2007
2007
2007
2007
2007
2007
2007
2007
2007
2007
2007
2007
2008
2008
2008
2008
2008
2008
2008
2008
2008
2008
2008
2008
2009
2009
2009
2009
2009
2009
2009
2009
2009
2009
2009
2009
0.90
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
SSE Rate
1.00
Serious Safety Event Rate (SSER) for MUMC
2005 - Present per adjusted 10,000 patient days
• Insert the chart
0.20
0.00
5
Serious Safety Events
Serious Safety Event Rate for MUMC
4
0.70
0.40
2
0.30
1
0.10
0
2010 Safety Goal
Event Free Calendar
250 Days
Navigating in New Waters…
• Completed a Business Case for Safety
– 68% decrease in cost of completing root cause
investigations and savings of over $100,000
– Costs associated with payouts and write-offs
decreased by 90% and savings of over $400,000
• More staff time to fish because we were not
spending time and effort on reactive steps for
safety
• Managers able to spend time on Precursor
Safety Events
“That’s all I have to say about
that…”
Questions?
Contact Information
Sherry Sweek
Southeast Georgia Health System
2450 Parkwood Drive
Brunswick, GA 31520
912.466.2124
ssweek@sghs.org
Martha White
Memorial University Medical Center
4750 Waters Ave, Suite 451
Savannah, GA 31404
912.350.7569
whitema2@memorialhealth.com