Quality and Patient Safety

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Quality and Patient Safety

• Handoffs
• Emily Carr Collaboration Project

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How Hazardous is Healthcare?
Dangerous (gt1/1000)
Regulated
Ultra-safe (lt1/100K)
100,000
Health Care
Driving
10,000
Total Lives Lost per year
1,000
Scheduled Airlines
Chartered Flights
Mountain Climbing
100
European Railways
Bungee Jumping
Chemical Manufacturing
10
Nuclear Power
100,000
1,000,000
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1
10,000
10,000,000
100
1,000
Number of encounters for each fatality
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To Err is Human/IOM Report

• Estimated that 44,000 to 98,000 Americans die
  each year as a result of adverse events.
• Adverse events result from system error rather
  than poor performance or purposefully harmful
  individuals.(Sharpe, 2003)

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CIHI Report -2004

• Canadian National Study that analyzed 3745 charts
• 7.5 hospitalized patients experience an adverse
  event
• 2/3 AE resulted in temp. disability and the other
  1/3 were more serious even deaths.
• Potentially 9,000-24,000 deaths annually due to
  adverse events.

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1 Error Rate (American Stats)

• 3 jumbo jet crashes every 2 days
• 16,000 pieces of lost mail every hour

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1 Error Rate

• 32,000 bank cheques deducted from the wrong
  account every hour.
• If we accepted 0.1 that would mean
• 99.9 2 unsafe landings at OHare daily.
  (Deming 1987)

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Steps to Improve Safety

• Basic Tenets of Human Error
• Everyone commits errors
• Human error is generally the result of
  circumstances that are beyond the conscious
  control of those committing the errors
• Systems or processes that depend on perfect human
  performance are fatally flawed
  Brown-Spath

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Process Redesign Solutions

• Design safer processes
• Barriers or safeguards can prevent untoward
  events
• X-ray confirmation of tube placement
• Mandatory repeat-backs (Starbucks)
• Door alarms
• Surgical site confirmation
• Brown-Spath

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The System in Action
133 People to take care of the Patient
The Patient
The Safer Patient Initiative, North Wales, UK
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Some Examples
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Human Factors
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Medication Safety

• Illegible Handwriting
• Look Alike/Sound Alike (Cerebrex, Celebrex)
• Unsafe Abbreviations
• Unsafe High-Risk Medications
• Verbal Order Read Back (Starbucks!)

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Packaging
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Communication

• Some examples of strategies are
• Surgical Safety Checklist
• SBAR
• Handoffs
• Shift Reports

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Safety Checklists

• Communication tools to empower teams by
  increasing situational awareness, teamwork and
  cooperation, problem-solving and decision-making,
  and leadership and management in complex
  environments
• Many industries
• Aviation and Aerospace,
• Energy (hydro, nuclear, petro-chemical),
• Heavy Construction
• Military

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Surgical Team in Action
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SBAR

• Situation what is the problem?
• Background pertinent information to problem at
  hand
• Assessment clinical staffs assessment
• Recommendation what do you want done and/or
  think needs to be done? (hardest for RNs to do)

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What do we mean by handoffs?

• Situations where information is passed from one
  caregiver to another
• Between individuals, teams, departments
• Different times of day and varying situations

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Shift Reports

• Reports between nurses at shift change
• Variety of different methods
• Tapes, verbal, written notes, etc.

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Some examples

• Youtube http//www.youtube.com/watch?vzw5cy8yoE
  bsfeaturerelated
• http//www.youtube.com/watch?vN-Xy-gbVbXkfeature
  related
• http//www.youtube.com/watch?vcyOAEcMgo3cfeature
  related
• http//www.youtube.com/watch?ve0mYe14UbVAfeature
  related
• http//www.youtube.com/watch?vNOKDrWyYM6Ifeature
  related

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Your Challenge

• Design an innovative strategy to improve
  shift-to-shift report for a variety of different
  nursing areas that
• Improves communication
• Efficient
• Timely
• Incorporates appropriate information to safety
  hand patient over to next shift

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Questions?