Patient Safety Resident Orientation

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Patient SafetyResident Orientation

• June 23, 2003

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Objectives

• Increase Safety mindfulness
• Brief review of concepts
• Patient safety
• Errors and adverse events
• Systems thinking
• Why adverse events happen
• What you can do to help prevent errors and
  adverse events

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Donald Rumsfeld Orders Breakfast At Dennys
First of all, there are things that we know. I
can look at this menu and see that. But theres
a danger there. Do I know that hash browns are
not included in the Original Grand Slam
Breakfast? It says that on the menu, which, by
the way, is nicely laminated and were grateful
to the laminator. But getting back to the
hash-brown potatoes, I should know that they
are not included.
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Donald Rumsfeld Orders Breakfast At Dennys-2
The real truth is, there are no knowns. This
is the whole new menu Are we in the past? No.
Are we using the pasts menu? No. Are there
things that we know we know? Not exactly.
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Donald Rumsfeld Orders Breakfast At Dennys-3
There are known unknowns. That is to say that
there are things that we now know we dont know.
But there are also unknown unknowns. These are
the things that we dont know we dont know. Got
that? I want you to note that on the check.
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(No Transcript)
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What Is Patient Safety?

• Freedom from adverse events related to medical
  error
• Freedom from adverse events related to our
  treatment

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Definitions

• Medical Error (IOM) The failure of a planned
  action to be completed as intended or the use of
  a wrong plan to achieve an aim
• Adverse Event any harm caused by medical
  management

Medical Errors
Adverse Events
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Systems Overview

• Structure
• Process
• Patterns
• Habits

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Human-Machine System(Socio-technical Systems)
One or more humans One or more machines
Machine any type of physical object, device,
equipment, facility, thing that people use
to carry out the desired goals
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The latent failure model of complex system
failuremodified from James Reason, 1991
allergy not communicated
ambiguous drug order
no maximum dose warnings
unclear expression of drug concentration
Inadequate practitioner orientation
Trigger
Communication System
Drug Labeling System
Patient Information System
Accident
Drug Info System
Other systems

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Human Error What We Know

• How we think and act
• Perception, Long term and short term memory
• Different types of activity
• Skill-based, rule-based, knowledge-based
• Errors will occur
• Risk factors

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Human Error Rates

• 0.003
• 0.03
• 0.1
• 0.25

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Some Human Factors that Increase Risk of Errors

• Fatigue, sleep loss
• Alcohol, drugs
• Illness
• Busyness and boredom
• Frustration, fear, anxiety, anger
• Stress
• overwork, interpersonal relations, time pressure
• Environmental factors
• Noise, temperature, visual stimuli, motion or
  other distractions

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Situational Awareness Red Flags

• Definitions
• Situational Awareness A shared understanding of
  whats going on and what is likely to happen
  next
• (shared mental model)
• Red Flag An indicator of loss / potential loss
  of situational awareness. May indicate
  something is wrong.

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Situational Awareness - An Overview

• A shared understanding of whats going on and
  what is likely to happen next
• Allows us to recognize events around us, act
  correctly when things proceed as planned, and
  react appropriately when they dont
• As with other Human Factors skills, SA is owned
  by the entire team

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Red Flags

• Red Flag An indicator of loss / potential loss
  of situational awareness. May indicate
  something is wrong. You can also think of red
  flags as internal or external stimuli that can
  degrade situational awareness.

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Mental model
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Red Flag
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RED FLAG CHECKLIST

• TASK MANAGEMENT
• Task Saturation
• Fixation / pre-occupation
• Failure to prioritize
• Being rushed, feeling pressured
• Deviating from normal practice
• Trying something new under pressure

• SELF-MANAGEMENT
• Boredom / fatigue
• Personal problems health mental, physical
• Workload, multi-tasking
• Intuition
• Doesnt feel right.
• Something feels wrong
• Attitude

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RED FLAG CHECKLIST

• COMMUNICATION
• Reduced /poor communication
• Feels awkward
• Interruptions/distractions
• Unresolved issues
• Verbal violence

• TEAM MANAGEMENT
• Ambiguity
• Uncertainty about the game plan
• Resource management workload, lack of planning,
  poor collaborative decision-making

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Obstacles to Medical Teamwork

• Excessive Professional Courtesy
• Halo Effect
• Passenger Syndrome
• Hidden Agendas
• Complacency
• High Risk Phase
• Strength of an Idea
• Task (Target) Fixation
• Hazardous Attitudes

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Hazardous Attitudes

• Cloud ones judgment
• Six specific ones
• Anti-authority
• Impulsiveness
• Invulnerability
• Machismo
• Resignation
• Get-there-it is

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Patient Safety What You Can DoTo Prevent
Accidents
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Prevention Strategies

• Prevent errors
• Prevent accidents
• Mitigate accidents

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IM SAFE Checklist

• Mechanism to Determine if You Are
  Fit and Ready to Perform

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IM SAFE Checklist (cont)

• Use IM SAFE Acronym
• Each Element Helps Answer the Question,
• Do I feel well enough to maintain that critical
  edge to make decisions and do what I need to do?
• Use Every Day To Evaluate yourself

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IM SAFE

• Illness
• Medication
• Stress
• Alcohol/Drugs
• Fatigue
• Emotions/Eating

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Verbalizing Red Flags to Help Restore S.A.
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Communicate Well

• At patient transfer
• With all of the patients care team
• Be an active communicator

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Be Assertive

• Got the persons attention
• Made eye contact, faced the person
• Used persons name
• Expressed Concern
• Stated the problem (clear, concise)
• Proposed action
• Re-asserted as necessary
• Reached decision
• Escalated if necessary

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Use SBAR

• Situation
• Background
• Assessment
• Recommendation

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Remember Teamwork

• You are part of a team
• Other residents and physicians
• Nurses
• Pharmacist
• Patient
• Everyone else

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Medication Safety
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Medication Safety Facts

• 10
• 150

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Medication Safety What You Can Do

• Dont use dangerous abbreviations
• Dont abbreviate Medication Names
• As much as possible, round doses to whole numbers
• Write legibly

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Dangerous Abbreviations

• u
• .7mg
• 4.0 mg
• lt and gt

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Medication Safety What you can do

• Know your patients medications
• For children less than 40 kg, write medication
  orders in mg/kg/dose and total dose and include
  weight
• Communicate your orders
• Be sure prescriptions are complete
• Repeat back telephone orders
• Double check dose when changing route of
  administration
• Double check high risk drugs such as infusions
• As much as possible dont bypass the process

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(No Transcript)
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Final Comments

• Identify yourself
• If you arent sure, assume you dont know and
  dont guess
• Dont be embarrassed to be wrong
• Be skeptical about knowledge of others
• Speak up
• Report errors including your own
• Report near misses and risk situations