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On the CUSP: STOP BSIOn the CUSP: STOP BSIThe Science of Improving Patient The Science of Improving Patient

SafetySafety

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Learning ObjectivesLearning Objectives

• To understand that every system is designed to achieve the results it gets

• To know the basic principles of safe design of both technical and teamwork

• To understand how teams make wise decisions

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The Problem is LargeThe Problem is Large

• In U.S. Healthcare system

– 7% of patients suffer a medication error

– Every patients admitted to an ICU suffer adverse

event

– 44,000- 98,000 deaths

– Nearly 100,000 deaths from HAI

– Approximately 30,000 deaths from CLABSI

– $50 billion in total costs

• Similar results in UK and AustraliaKohn To err is human

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10.5Alcohol dependence

22.8Hip fracture

40.7Urinary tract infection

45.2Headaches

45.4Diabetes mellitus

48.6Hyperlipidemia

53.0Benign prostatic hyperplasia

53.5Asthma

53.9Colorectal cancer

57.2Orthopedic conditions

57.7Depression

64.7Hypertension

68.0Coronary artery disease

68.5Low back pain

Percentage of Recommended Care Received Condition

McGlynn et al, NEJM 2003; 348(26):2635-2645

RAND Study Confirms Continued RAND Study Confirms Continued Quality Gap Quality Gap

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How Can This Happen?How Can This Happen?

Need to view the delivery of healthcare as a science

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How Can We Improve?How Can We Improve?Understand the Science of SafetyUnderstand the Science of Safety

• Every system is perfectly designed to achieve the results it gets

• Understand principles of safe design – standardize, create checklists, learn when things go wrong

• Recognize these principles apply to technical and team work

• Teams make wise decision when there is diverse and independent input

Caregivers are not to blameCaregivers are not to blame

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SystemSystem FailureFailure LeadingLeading toto ThisThis ErrorError

Catheter pulled withPatient sitting

Communication betweenresident and nurse

Lack of protocol For catheter removal

Inadequate trainingand supervision

Pronovost Annals IM 2004; Reason

Patient suffers

Venous air embolism

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System Factors Impact System Factors Impact SafetySafety

HospitalHospital

Departmental FactorsDepartmental Factors

Work EnvironmentWork Environment

Team FactorsTeam Factors

Individual ProviderIndividual Provider

Task FactorsTask Factors

Patient CharacteristicsPatient Characteristics

InstitutionInstitutionalal

Adopted from VincentAdopted from Vincent

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Evidence Regarding the Impact of Evidence Regarding the Impact of ICU Organization on PerformanceICU Organization on Performance

• Physicians

• Nurses

• Pharmacists

Pronovost JAMA 1999, 2002; Pronovost ECP 2001

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Aviation Accidents Aviation Accidents per Million Departuresper Million Departures

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Systems Systems

• Every system is designed to achieve the results it gets

• To improve performance we need to change systems

• Start with pilot test one patient, one day, one physician, one room

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Principles of Safe DesignPrinciples of Safe Design

• Standardize – Eliminate steps if possible

• Create independent checks

• Learn when things go wrong– What happened– Why– What did you do to reduce risk– How do you know it worked

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StandardizeStandardize

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Line Cart Contents – 4 Line Cart Contents – 4 DrawersDrawers

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Eliminate StepsEliminate Steps

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Create Independent Create Independent ChecksChecks

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2 Year Results from 103 2 Year Results from 103 ICUsICUs

Time period Median CRBSI rate Incidence rate ratio

Baseline 2.7 1

Peri intervention 1.6 0.76

0-3 months 0 0.62

4-6 months 0 0.56

7-9 months 0 0.47

10-12 months 0 0.42

13-15 months 0 0.37

16-18 months 0 0.34

Pronovost NEJM 2006

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Principles of Safe Design Principles of Safe Design Apply to Technical and Apply to Technical and

TeamworkTeamwork

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Basic Components and Process of Basic Components and Process of CommunicationCommunication

Elizabeth Dayton, Joint Commission Journal, Jan. 2007

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pond

ents

repo

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abo

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team

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ICUSRS Data

ICU Physicians and ICU RN ICU Physicians and ICU RN CollaborationCollaboration

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Teamwork ToolsTeamwork Tools

• Daily goals

• AM briefing

• Shadowing

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Teams Make Wise Decisions When Teams Make Wise Decisions When There is Diverse and Independent There is Diverse and Independent

InputInput

• Wisdom of Crowds

• Alternate between convergent and divergent thinking– Get from OR to balcony

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Don’t Play Man DownDon’t Play Man Down

When you feel something say somethingWhen you feel something say something

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Action ItemsAction Items

• Pick one area and reflect on the systems that predict performance– Walk and observe the process

• Work to standardize one process such as central line cart

• Pilot test it

• Ensure all staff know the science for improving patient safety

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ReferencesReferences

• Berwick DM. A primer on leading the improvement of systems. BMJ 1996;132:619-22.

• Langley G, Nolan K. The improvement guide: a practical approach to enhancing organizational performance. Hoboken, NJ: Jossey-Bass Publishers 1996.

• Needham DM, Thompson DM, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004;32:2227-33.

• Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12):1025-1033.

• Pronovost PJ, Angus DC, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288(17):2151-2162.

• Reason J. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000.