Taking Care of Patients Safely
Pitt County Memorial Hospital
Let’s not learn patient safety by
accident…

Willie King, age 51 with a
history of diabetes,
consented to a have a below
knee amputation on his right
foot. Surgeons amputated is
left foot in error.

Prior to surgery, Willie joked
with the medical staff, “You
know which one it is, don’t
you? I don’t want to wake up
and find the wrong one
gone.”
Slide 2
Let’s not learn patient safety by
accident…

Joan Faulkner was
badly burned in a
hospital in North
Carolina when a
cauterizing tool ignited
the oxygen that she
was receiving during a
routine surgical
procedure. Her top lip
was burned off, her
face, neck and chest
suffered 2nd and 3rd
degree burns.
Slide 3
The Costs of Mistakes

The Institute of Medicine estimates 44,000 to
98,000 deaths occur each year due to medical
errors

An additional 100,000 deaths occur each year
from hospital-acquired infections, half of which
were preventable

Probability of a patient dying in a hospital due to
an human error is 1 in 300.
Slide 4
These types of errors can happen
at any hospital!
Slide 5
Learning About Human Error
Slide 6
Why Do Events Happen?
Sometimes an error occurs, but an event or injury
is prevented by an internal system of checks
Significant
events or
injuries
Sometimes
multiple errors
line up to allow
a significant
event or injury
to occur
From Managing the Risks of Organizational
Accidents, James Reason
Slide 7
Human Error Classification
There are 3 major categories of
errors



Skill-based errors
Rule-based errors
Knowledge-based errors
Slide 8
Human Error Classification
Skill-Based Errors
Errors made when performing acts or
tasks while utilizing skills on “autopilot”
Skill-based errors most often occur
during lapses in attention (e.g. when
we’re pressed for time, or when the
action is so routine we don’t pay
attention).
Slide 9
Human Error Classification
Rule-Based Errors
Errors made when performing acts or
tasks that require application of rules
accumulated through experience and
training
Types of Rule-Based Errors
 Wrong Rule
 Misapplication of Correct Rule
 Non-Compliance with Rule
Slide 10
Human Error Classification
Knowledge-Based Errors
Errors made when performing acts
related to new or unfamiliar situations
that require problem solving or when
a rule does not exist or is unknown to
the performer
Types of Knowledge-Based Errors
 Decision-making
 Problem solving
Slide 11
Behavior Based Expectations & Tools
to Assist in the Reduction of Errors
Behaviors for Physicians
1. Pay Attention to Detail Self-check using STAR
2. Communicate Clearly
3. Handoff Effectively
4. Support Each Other
Repeat-back
Clarifying questions
Phonetic/numeric clarification
SBAR
SBAR
Speak-Up/Listen using AAA
Encourage questions
Slide 13
BBE #1: Pay Attention to Detail
Focus attention to always think before we act.
Why should we do this?
 To avoid unintended slips or lapses
 To reduce the chance that we’ll make an error when we’re
under time pressure or stress
When should we do this?
 Before we act, speak, and document
Slide 14
Error Prevention Tool
Self Checking Using STAR
Stop:
Pause for 1 to 2 seconds to focus on
what you’re about to do
Think:
Think about what you’re about to do –
focus on the action
Act:
Concentrate and perform the task
Review:
Check to see if the task was done right
Slide 15
BBE #2: Communicate Clearly
Communicate correct information in a timely and appropriate
manner.
Why should we do this?
 To ensure that we hear things correctly and that we
understand things correctly
 To prevent avoid wrong assumptions and
misunderstandings that could cause us to make wrong
decisions
When should we do this?
Whenever we communicate information – either in person or
over the phone – that could affect the care and safety of a
resident or an employee
Slide 16
Error Prevention Tool
3-Way Repeat Backs
When information is transferred...
1
Sender initiates communication using
Receivers Name. Sender provides an order,
request, or information to Receiver in a clear
and concise format.
2
Receiver acknowledges receipt by a repeatback of the order, request, or information.
3
Sender acknowledges the accuracy of the
repeat-back by saying, That’s correct! If not
correct, Sender repeats the communication.
Slide 17
Error Prevention Tool
Clarifying Questions
Ask 1 to 2 clarifying questions
When in high risk situations
When information is incomplete
When information is ambiguous
WHY: To reduce the probability of making a wrong
assumption. Asking clarifying questions reduces the
risk by 2 1/2 times!!
HOW: Phrase your clarifying questions in a positive way
and in a manner that will get an answer that improves
your understanding of the information
Slide 18
Error Prevention Tool
Phonetic Clarifications
letter followed by a word that begins with the letter. For
For sound alike words, say the letter followed by a
example:
word that begins with the letter. For example:
A
B
C
D
E
F
G
H
I
Alpha
Bravo
Charlie
Delta
Echo
Foxtrot
Golf
Hotel
India
J
K
L
M
N
O
P
Q
R
Juliet
Kilo
Lima
Mike
November
Oscar
Papa
Quebec
Romeo
S
T
U
V
W
X
Y
Z
Sierra
Tango
Uniform
Victor
Whiskey
X-Ray
Yankee
Zulu
Slide 19
Error Prevention Tool
Numeric Clarifications
For sound alike numbers, say the number and then speak
each digit of the number. For example:
15…that’s one-five
50…that’s five-zero
Slide 20
BBE #3: Handoff Effectively
Handoff patients or tasks by giving appropriate information and ensuring
understanding and ownership.
Why do we have this behavior?
 To ensure that complete and accurate information about the patient,
project, or task is communicated when responsibility transfers from
one individual to another
When should we practice this behavior?
 When turning responsibility for a patient, project, or task to another
individual
Slide 21
Error Prevention Tool
SBAR for an Effective Handoff
When transitioning care to another physician, or when requesting a
consult on a patient, use the SBAR technique to organize your
communication
Situation: Describe the situation, patient or question
Background: Highlight the important information, precautions, issues
Assessment: Outline your read of the situation, problems and precautions
Recommendation: State your recommendation, request or plan
Slide 22
BBE #4: Support Each Other

Speak Up for Safety by using the Triple A technique
Ask (Do you think we should order a CXR?)
Advocate (I think we need to order a CXR.)
Assert (I’m concerned that we may miss something if we
don’t get a CXR.)

Tips
Use the lightest touch possible…
When asserting, use the safe word: “concern”
If not successful and you’re still worried, then use chain of
command
Slide 23
Encourage Questions
Encourage questions by inviting questions and
positively reinforcing questions when asked.
Asking a question is an emotional security issue. Foster a
culture of critical thinking by encouraging questions. Invite
questions, and use positive reinforcement when questions
are asked.
Top 3 Statements to Encourage Critical Thinking1
1. “What do you think?”
2. “That is an interesting question”
3. “Let’s explore this”
1
Rubenfeld, “Critical Thinking Tactics for Nursing”
Slide 24