Learning from a Defect:
Team Exercise
Jill Marsteller, PhD, MPP
© 2007 JHU Quality and Safety
Research Group
Workshop Objectives
• Describe the purpose and vision of the ICU Safe Care
Initiative/Comprehensive Unit-Based Safety Program.
• Describe the process used to identify and eliminate system defects.
• List three tools or strategies used to improve teamwork and build a
safety culture.
• State research and best practices in reducing infections, preventing
central line infections, and going beyond the bundle.
© 2007 JHU Quality and Safety
Research Group
© 2007 JHU Quality and Safety
Research Group
What is a Defect in Patient
Care?
Definition-defect
A defect is any clinical or operational
event or situation that you would not want
to happen again. These could include
incidents that you believe caused harm or
put patients at risk for harm (Pronovost, P. et al., (2006) Tool
tutorial: A practical tool to learn from defects in patient care Journal of Quality and Patient Safety,
32, 102-108.)
© 2007 JHU Quality and Safety
Research Group
Sources of Defects
•
•
•
•
•
•
Adverse event reporting systems
Sentinel events
Claims data
Infection rates
Complications
How is the next patient going to be
harmed
© 2007 JHU Quality and Safety
Research Group
Complication, LOS, Charges*
Complication
Increased
LOS
Charges
Pneumothorax 4 days
$17,000
PE or DVT
5 days
$22,000
Hip Fx
5 days
$13,500
Respiratory
failure
9 days
$53,000
DT’s
9 days
$55,000
Post op sepsis 11 days
$58,000
*Miller JAMA 2003
© 2007 JHU Quality and Safety
Research Group
System Failures Can Come From Many
Factors in an Organization
8 Major Factors that
can contribute to
System Failures
1.Institutional
2.Hospital
3. Departmental
4. Work
5.Environment
6. Individual Provider
7. Task Factors
8. Patient Characteristics
7
System Factors Impact Safety
© 2007 JHU Quality and Safety
Research Group
Safety Efforts
• Focus on Harm versus errors
Harm- ignorance of causality- provider level
Error see provider level
• Proactive versus reactive
© 2007 JHU Quality and Safety
Research Group
LFD: A Four-step Process
The LFD Process steps
1.Answers the question: “What happened?”
2.Evaluates the defect
3.Lists specific actions needed to reduce the
likelihood the defect will happen again
4.How do you know the action taken got the
results you wanted?
© 2007 JHU Quality and Safety
Research Group
Step 1. Answer-What
happened?
The Role of the investigator:
– Construct a brief, concise statement of the “story”
surrounding the incident.
– Reconstruct the timeline of the incident or near
miss
– Try to “view the world” as one of those involved in
the event at the time the event happened: How
were those involved thinking about the problem?
Why did they make the decision they made? Why
did they take the course of action that was taken?
© 2007 JHU Quality and Safety
Research Group
Step 2. Evaluate the defect
Evaluate the defect by
– Reviewing and checking all the factors
that caused or negatively contributed to
patient harm,
– Reviewing and checking all positive
factors that might have reduced or
eliminated harm
© 2007 JHU Quality and Safety
Research Group
Probes to Contributing Factors: Examples
Patient
Was the patient acutely ill? Agitated? Anxious?
Aged? Language barrier? Personal or social
issues?
Task
Was a stated policy/protocol or guidelines followed?
Were labs available for decision making?
Caregiver
Fatigue? Lack of experience by care givers? Any
physical or mental health issues with provider?
Team
Were handoffs (verbal or written) clear? Was there a
clearly identified team leader? Were team members
hearing one another’s concerns?
Training and Education
Was established protocol followed? Were caregivers
knowledgeable and competent?
© 2007 JHU Quality and Safety
Research Group
Probes to Contributing Factors:
Examples Continued
Patient
Was the patient acutely ill? Agitated? Anxious?
Aged? Language barrier? Personal or social
issues?
Information
Technology
Did technology create an error? Technology
malfunction?
Local Environment
Were there adequate supplies and equipment? Were
there adequate human resources to care for patients
and support staff?
Institutional
Environment
Was there adequate staff (lab, pharmacy, nurses)?
Other
© 2007 JHU Quality and Safety
Research Group
Step 3. Create an Action Plan
List specific actions to reduce the likelihood
of the defect happening again.
-determine who will lead the defect
investigation
-establish a follow-up date
-measure risk reduction using either a
qualitative or quantitative measure.
© 2007 JHU Quality and Safety
Research Group
Step 3. Action Plan: Template Example
Create a specific action plan to mitigate the occurrence
of this type of incident or the near miss
Specific actions
needed to
reduce the risk
of the defect?
Who will lead
this effort
Follow-up date
How will you
know the risk
to the patient is
reduced?
© 2007 JHU Quality and Safety
Research Group
Step 4. How will you evaluate the impact of the
intervention?
1.Develop a framework to assess the impact
of the intervention.
2.What are your variables?
3.How will they be measured?
4.How long will you evaluate?
Utilize your clinical experts- often your
frontline staff. If they don’t view it as
important or effective it unlikely to be
successful
© 2007 JHU Quality and Safety
Research Group
Step 4. How will you evaluate the impact of the
intervention?
Example: VRE reduction
Developed a new policy and procedure for skin
antisepsis.
After education and Implementation
1.Evaluate the staff’s knowledge of the policy and
procedure.
2.Is the policy and procedure being adhered to by the
staff?
3.Summary of the staff’s perception of the impact of the
intervention in preventing the defect?
© 2007 JHU Quality and Safety
Research Group
Walk Through- Case Study 1
© 2007 JHU Quality and Safety
Research Group
•Safety Tips:
Team debriefings at change of shift or hand-offs.
Time-outs for assessment prior to procedures.
Checklist guidelines for complicated procedures.
CASE IN POINT…..This case involves a chronically, critically ill white male over 65 years of age admitted to the ICU with a GI
neoplasm. He had undergone GI surgery during this hospital admission and at the time of this adverse event was
mechanically ventilated, with multiple infusions, inatropes and vasopressors. Due to failure to wean from mechanical
ventilation, he underwent an uneventful percutaneous tracheostomy. During the first change of the patient’s
percutaneous tracheostomy, the airway was lost, likely because the Shiley was placed in the subcutaneous tissue
rather than the trachea, leading to hypoxia, hypotension, cardiac arrest and death. In reviewing the activities leading
to this adverse event: (1) there was miscommunication between nursing staff and ICU team regarding the policy for
trach replacement, resulting in a request for tracheostomy replacement; (2) surgical chief changed the trach after
evening change of shift without adequate back-up; (3) surgical chief was unaware of patient’s worsening condition
throughout the day and fellow was not aware of the planned trach change; (4) no verbal or written note given at
change of shift noting difficulty of trach placement (done in OR); (5) neither the ICU attending (handling two
admissions at the time) nor the surgical attending were notified of tracheostomy change in progress; (6) incorrect
replacement trach tube used and inadequate positioning of patient; (7) ICU and surgical care teams failed to diagnose
inadequate placement of replacement tube over red rubber catheter, attributing no EtCO2 or breath sounds to large
cuff leak.
SYSTEM FAILURES:
Poor communication among teams.
Standard policy and procedure for percutaneous tracheotomy
replacement was not followed.
Surgical chief’s limited knowledge of trach placement difficulty, poor
trach placement skills.
OPPORTUNITIES for IMPROVEMENT:
•2-5 minute debriefing between teams at change of shift
or hand-offs.
•All staff stop and have a time-out prior to performing a
procedure to discuss plan and any risks.
Develop a step-by-step checklist for performing a
tracheotomy; make it standard policy to perform with
ICU attending present.
Proper debriefing and clear procedural guidelines.
Case Number 2
• Take a few minutes and familiarize with
the case
• Review the investigate a defect tool.
• Discuss with your team
© 2007 JHU Quality and Safety
Research Group
Workshop Objectives
• Describe the purpose and vision of the ICU Safe Care
Initiative/Comprehensive Unit-Based Safety Program.
• Describe the process used to identify and eliminate system defects.
• List three tools or strategies used to improve teamwork and build a
safety culture.
• State research and best practices in reducing infections, preventing
central line infections, and going beyond the bundle.
© 2007 JHU Quality and Safety
Research Group