Professional Documents
Culture Documents
Patient Safety Past, Present, Future: Breakfast With The Chiefs
Patient Safety Past, Present, Future: Breakfast With The Chiefs
2
Mission
To provide national leadership in building and
advancing a safer Canadian health system
Vision
We envision a Canadian health system where:
• Patients, providers, governments and others work together to build and
advance a safer health system;
• Providers take pride in their ability to deliver the safest and highest quality
of care possible; and
• Every Canadian in need of healthcare can be confident that the care they
receive is the safest in the world.
3
Definitions
Patient Safety:
The reduction and mitigation of unsafe acts within the health-
care system, as well as through the use of best practices
shown to lead to optimal patient outcomes.
Canadian Patient Safety Dictionary, 2003
Adverse Event:
An adverse event is an unintended injury or complication
which results in disability, death or prolonged hospital stay,
and is caused by health-care management.
Wilson et al
4
Evolution of Patient Safety
Codman, 1915
5
What Patient Safety Is and Is Not
6
8
What We Know
Canadian Institute for Health Information
(2004)
10
Medical Error Citations
Medical Error Citations collated by the National Patient Safety Foundation
for the period 1939-98.
120
100
80
Citations
60
40
20
0
Year
11
Adverse Events
• Delayed or missed diagnoses • Lost, delayed, or failures to follow up
• Medication errors reports
• Wrong side surgery • Retention of foreign object following
• Wrong patient surgery surgery
• Equipment failure • Contamination of drugs, equipment
• Patient identity • Intravascular air embolism
• Transfusion errors • Failure to treat neonatal
•
hyperbilirubinemia
Mislabeled specimen
• Stage lll or lV pressure ulcers acquired
• Patient falls
after admission
• Time delay errors
• Wrong gas delivery
• Laboratory errors
• Deaths associated with restraints or
• Radiology errors bedrails
• Procedural error • Sexual or physical assault
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Why Do Adverse Events Happen?
• In any system or organization that involves
humans, error is inevitable because there is a
wide variation in performance both within and
between people
• Evidence is accumulating that some human
dispositions towards error are hard-wired
• Only a small proportion of error is egregious
• Ambient conditions and systemic design increase
the likelihood of error
• Error has been described as the ‘essential
friction’ within all systems
13
Sources of System Error
Adverse Events
• Overall culture
• Education/Training/Experience
• System design / HFE
• Resource availability
• Demand/Volume
• Throughput Impedance
• Shift-work/schedules
14
A Culture of Safety
31,033 Pilots, Surgeons, Nurses and Residents Surveyed*
*Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross
sectional surveys. BrMedJour, 3-18-2000.
15
Comparative Reliability Between
Industries
PPM Difficulty with Referral
1,000,000 Mammography Screening
• ••
100,000
• •• Tax Advice
(phone-in) (140,000 PPM)
10,000 Low
Back TX
Post Heart
Attack Medication • Airline Baggage Handling
18
Human Factors
19
Human Factors
Fatigue
• 24 hours without sleep is equivalent to a blood
alcohol level of 0.10 – a 30% decrease in cognitive
processing
• Nurses are 3 times more likely to make mistakes
after 12 hours on the job
• Interns made 30% more errors in ICU patients
when on traditional 24 hour call schedules
• The best countermeasure for fatigue is teamwork
–more people in the movie
• 3 major disasters related to night time workers:
Exxon Valdez, Chernobyl, and Three Mile Island.
Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation
20
21
Association Between Evening Admissions and Higher
Mortality Rates in the Pediatric Intensive Care Unit
Yeseli Arias, Doublas S. Taylor, and James P. Marcin
Pediatrics 2004; 113: 530-534
4.5
4 4.1
3.9
3.5
3
2.5
Day 2
Night
1.5
1.8 1.9
1 0.9 1.2
0.9
0.5
0.4
0
Sepsis Cardiac Cardiac Time of
Disease Arrest Birth*
22
Human Factors
Multitasking, Interruptions, Distractions
23
Human Factors
Inherent Human Limitations
24
Patient Safety: Barriers to Action
• Leadership turnover
• Jurisdictional conflicts
EHR System
Changes to
Create a
Culture of
Safety
Education and
Professional Information
Development and Communication
27
A Systems Approach
28
Reason’s Swiss Cheese Model
29
CPSI Strategies and Activities
• Adverse Event Reporting and
Learning System
30
Development of a Canadian Adverse Events
Reporting and Learning System (CAERLS)
A major initiative in the 2006/07 CPSI Action Plan is to explore the
development of a Canadian Adverse Event Reporting & Learning System to
enable a patient safety knowledge base, create a repository and facilitate
knowledge transfer to inspire innovation and safety improvement.
History
• In January of 2005 CPSI partnered with ISMP Canada and
Saskatchewan Health, to begin work on the development of the
Framework.
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National Guidelines for Disclosure
of Adverse Events
• National Working Group
• Project Charter – full endorsement
• Background Document
• Literature Search and Review
• Final Draft – Feb 2007
• Nationwide Consultation – Mar – April 2007
• Nationwide Endorsement – May – Aug 2007
• Publication and Distribution – October 2007
(Halifax 7)
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Safer Healthcare Now!
Interventions
34
Campaign Structure
Campaign Support
SHN National Steering Committee
Secretariat - CPSI
Operations
Measurement Communication
Working Group & CMT Working Group
Education & Resource
Working Group
35
West Ontario Atlantic Quebec Total
Healthcare
Delivery
Organizations
[includes hospitals,
agencies, services 45 98 23 10 176
and regions (with
one or more
hospitals
participating)]
36
Teams Continue to Enroll
Saferhealthcare Overview Total # Enrolled Teams September 2005 to January 2007
600 579
541
491
500
443
403
400
296
300
200
118
100
0
Total # of Teams EnrolledTeams
x Chart
50
UCL = 46.11
40
VAP rate (VAP cases/1000 vent days)
30
Mean = 10.30
20
10
Goal 8.4
LCL = 0
0
May- Jun-04 Jul-04 Aug- Sep- Oct-04 Nov- Dec- Jan-05 Feb- Mar- Apr-05 May- Jun-05 Jul-05 Aug- Sep-
04 04 04 04 04 05 05 05 05 05
Month
38
Ventilator Associated Pneumonia (VAP)
St. Paul’s Hospital (SK)
Days between VAP cases
Nov-1-99
Nov-30-05
Jun-14-01
Jul-3-99
June -15-00
Dec-20-99
Mar-31-00
Mar-16-02
Sep- 30-05
Mar-5-99
May-31-99
Sep-12-00
Sep-9-03
Aug-8-04
May-11-05
229 days since last reported VAP
Month
10 14
8 12
VAP rate per
6 10
1000
days
VAP/1000 8
4
6
2 4 Jan-Nov
0 2
0
Aug-
Dec-
Dec-
Aug-
Aug-
Dec-
Aug-
Apr-03
Apr-05
Apr-02
Apr-04
Dec
7.0
5.0
Rate per 1000 line days .
3.0
2.0
1.0
0.0
Sep-04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 Apr-05 May-05 Jun-05 Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06
40
Rapid Response Team
University of Alberta
# Cardiac ICU
Arrests ALOS
Pre-implementation 7 (4.0 per 100 separations) 10.2
Post-implementation 1 (0.8 per 100 separations) 6.4
Total # calls 24
41
CPSI Strategies and Activities
• Research
• Professional Development
• Simulation
• National Hand Hygiene Campaign
• Patient Safety Competencies Project
• Executive Patient Safety Series
• Canadian Patient Safety Officer Course
42
CPSI Strategies and Activities
Research - 2005
– With CIHR, CHSRF and safety leaders safety
research priorities
– Launched 2005 CPSI grants competition
• 327 registered projects
• 125 full applications received
• 57 peer-reviewed
• 28 funded ($1.9M)
– Co-funded with CHSRF two REISS programs
• Pediatric and Adult Acute Care, Family Medicine
– Two Projects Funded with CIHR
43
CPSI Strategies and Activities
Research - 2006/07
– Launched 2006/07 CPSI grants competition
• 64 full applications received
• 35 peer-reviewed
• 15 funded ($1.4M)
– Launched with CIHR a Patient Safety Priority
Announcement
• Grants
• Fellowships
– Partner in the “Listening for Direction” health services
research priority setting initiative with CHSRF, CIHR,
CADTH, CH, CIHI, Health Canada, Statistics Canada
– Partnered with CIHR, CADTH, CIHI, Statistics Canada,
CHSRF to study post marketing surveillance and
effectiveness
44
CPSI Strategies and Activities
Professional Development
- Leading the Safety Process
In partnership with the CMA and the CMPA, CPSI is
developing a workshop in which participants will learn:
46
CPSI Strategies and Activities
National Hand Hygiene Campaign
The Canadian Patient Safety Institute, the Canadian Council for Health
Services Accreditation, the Public Health Agency of Canada and the
Community and Hospital Infection Control Association are working
together to support, supplement and integrate existing hand hygiene
initiatives locally, regionally and provincially, by developing and
implementing a hand hygiene campaign across Canada.
Campaign Goal:
•To promote the importance of hand hygiene in reducing the
spread of healthcare associated infections in Canada
Campaign Objective:
•To respond to the needs of healthcare organizations for capacity building,
leadership development, and/or the production of tools to help promote
hand hygiene
47
CPSI Strategies and Activities
Patient Safety Competencies Project
Objectives:
• Identify the key knowledge, skills and attitudes
related to patient safety competencies for all
healthcare workers
• Develop a simple, flexible framework that will
act as a benchmark for training, educating and
assessing healthcare professionals in patient
safety
• Help make patient safety competencies easy for
everyone to understand and apply
48
CPSI Strategies and Activities
Executive Patient Safety Series
Objectives:
• Describe how you can better fulfill your
responsibilities and accountabilities for patient
safety at the Board/Executive level;
• Understand the methods to effect a cultural shift in
your organization to improve patient safety;
• Create and share safety practices that can be
adapted and established in your organization; and
• Position safety in the context of quality in your
organization.
49
CPSI Strategies and Activities
Canadian Patient Safety Officer Course
With the help of faculty experts, this course will be delivered through
interactive workshops, networking and presentations by patient safety
leaders for healthcare professionals and leaders involved in patient safety
(patient safety officers, clinical managers and physicians)
Overall objectives:
• Provide the skills to create, implement, and maintain a vigorous and
focused patient safety program
• Help develop detailed, customized patient safety strategies and
implementation plans
• S-B-A-R
– Situation
– Background
– Assessment
– Recommendation
51
Patient Safety
Is It Getting Better?
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What is HSMR?
• HSMR track changes in hospital mortality
rates in order to:
– Reduce avoidable deaths in hospitals
– Improve quality of care
• Developed in the UK in mid-1990s by Sir Brian
Jarman of Imperial College
• Used in hospitals worldwide (i.e. UK, Sweden,
Holland and US)
53
HSMR is easy to interpret
• Equal to 100
– No difference between facility’s mortality
rate and average rate
• More than 100
– Facility’s mortality rate is higher than the
average rate
• Less than 100
– Facility’s mortality rate is lower than the
average rate
54
Much has Been Done …
Trend in Age-Adjusted 30-Day In-Hospital
Death Rate
55
What Does Average Mean?
(Results from Baker/Norton)
56
Efforts to Date
(Preliminary based on data as of March 2006)
57
But Variations Persist
Distribution of HSMR for facilities with at least 2000 discharges, FY
2004/05 – Adapted international method
30
25
Number of Facilities
20
15
10
0
41-60 61-70 71-80 81-90 91-100 101-110 111-120 121-130 131-140 141-150 151-160
HSMR
58
Human Error – the New View
59
Human Error – the New View
60
61
62
Conclusion
63
Conclusion
64
Conclusion
65
“Culture eats strategy for lunch
over & over again”
Marc Bard
67
High Reliability Organizations are Pre-occupied
with the Possibility of Failure