Revisiting Learning From Defects: An Intervention to Learn from Mistakes David A. Thompson DNSc, MS, RNAssociate ProfessorArmstrong Institute for Patient Safety and QualityJohns Hopkins University School of Medicine

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Culture is Important

• Respecting the wisdom of frontline workers

• Assessing the context of care: provider teamwork (collaboration), perceptions of management, patient safety normshierarchy

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Culture is Important

Joint Commission data show that Communication breakdowns are the leading root cause of:

• Sentinel Events• Medication Errors• Perinatal Deaths & Injuries• Delays in Treatment• Wrong Site Surgeries• Ventilator events

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Culture is Measurable

• Culture is local• Data collected and interpreted at unit level• Representativeness -vs-

Representative Mess– Partial sampling is not adequate for year to

year comparisons• High Response Rates are easy to interpret &

difficult to ignore

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ICU Physicians and ICU RN Collaboration

51%

88%

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K P L &D

RN rates ICU Physician ICU Physician rates RN

% o

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team

work

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Teamwork Disconnect

• RN: Good teamwork means I am asked for my input

• MD: Good teamwork means the nurse does what I say

70

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Teamwork Climate Across Michigan ICUs

 

No BSI 21% No BSI 44% No BSI 31%

No BSI = 5 months or more w/ zero

The strongest predictor of clinical excellence: caregivers feel comfortable speaking up if they perceive a problem with patient care

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Steps of CUSP

1. Educate staff on Science of Safety 2. Identify defects3. Assign executive to adopt unit4. Learn from one defect per quarter5. Implement teamwork tools

Pronovost J, Patient Safety, 2005

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Lesson Learned: Errors are the result of system failures

“Every System is Perfectly Designed to Achieve the Results it Does”

Batalden

Berwick http://www.mederrors.org/1998/html/keynote.html

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System Factors Impact Safety

HospitalDepartmental Factors

Work EnvironmentTeam Factors

Individual ProviderTask Factors

Patient Characteristics

Institutional

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The Work of Adaptive Change

• Determining the direction – what must change

• Determining the methods – how to change

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Step 4: Learning from Mistakesaka Learning from defects

• What happened?

• Why did it happen (system lenses) ?

• What could you do to reduce risk ?

• How do you know risk was reduced ?– Create policy / process / procedure– Ensure staff know policy– Evaluate if policy is used correctly

Pronovost 2005 JCJQI

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0

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Basic Clinical HealthServices

Type of Research

Annual US Health Research Funding

FederalPharma

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What is a Defect?

• Anything you do not want to have happen again

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Assessing Defects

• Staff Safety assessment– Please describe how you think the next patient in

your unit/clinical area will be harmed.• Adverse event reporting systems• Sentinel events• Complications• Infection rates• Mortality and morbidity conference• Claims data

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4 Questions to Learn from Defects

• What happened?• Why did it happen?• What will you do to reduce the chance it

will recur?• How do you know that you reduced the

risk that it will happen again?

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What Happened?

• Reconstruct the timeline and explain what happened

• Put yourself in the place of those involved, in the middle of the event as it was unfolding

• Try to understand what they were thinking and the reasoning behind their actions/decisions

• Try to view the world as they did when the event occurred

Reason J. Human Error. Cambridge, UK: Cambridge Univ Pr; 1990.

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Why did it Happen?

• Review the list of factors that contributed to the incident and check off those that negatively contributed and positively contributed to the defect

• Negative contributing factors are those that harmed or increased risk of harm for the patient

• Positive contributing factors limited the impact of harm

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Why did it Happen?

• Complete the contributing factors section

• Items may positively contribute, negatively contribute, or not apply (n/a)

• These are examples but you may identify factors that are not listed, if so, write down

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Why did it Happen?

• Review the list of contributing factors and identify the most important factors related to this event.

• Rate each contributing factor on its importance to this event and future events.

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What will you do to reduce the risk?

• Safe design principles– Standardize what we do

• Eliminate defects– Create independent checks– Make it visible

• Safe design applies to technical and team work

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What will you do to reduce the risk?

• Select top interventions (2 to 5) and develop intervention plan

• Assign person and task follow-up date

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Strength of InterventionsWeaker Actions Intermediate Actions Stronger Actions

Double Check Checklists/ Cognitive Aid Architectural/physical plant changes

Warnings and labels Increased Staffing/Reduce workload

Tangible involvement and action by leadership in support of patient safety

New policy, procedure, or memorandum

Redundancy Simplify the process/remove unnecessary steps

Training and/or education

Enhance Communication (read-back, SBAR etc.)

Standardize equipment and/ or process of care map

Additional Study/analysis

Software enhancement/modifications

New device usability testing before purchasing

Eliminate look alike and sound- a-likes

Engineering Control of interlock (forcing functions)

Eliminate/reduce distractions

Adapted from John Gosbee, MD, MS Human Factors EngineeringRemember sometimes a weaker action is

your only option.

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Near Miss

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A Medication Error Story

• 63 year old man with sternal infection transferred to the ICU

• Allergy to Penicillin noted in chart• Treatment includes Piperacillan• 25 minutes after dose, patient arrests• Antibiotic reaction regarded as likely

trigger

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A Medication Error Story

Nurse borrows medication fromanother patient

Fax system for ordering medications

is broken

Tube system for obtaining medications

is broken

Nurse gives the patient a medication to which he

is allergic

ICU nurse staffing

Patient arrests and dies

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Impact of ICU Nurse Staffing on Outcomes*

• Fewer ICU nurses associated with increased LOS risk of pulmonary complications

• Pulmonary insufficiency• Reintubation of trachea • Pneumonia

*Pronovost PJ, Dang D, Dorman T, et al. Intensive care unit nurse staffing and the risk for complications after abdominal aortic surgery. Eff Clin Pract. 2001;4:199-206.

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Impact of Pharmacist on Outcomes*

• Pharmacist participation on daily rounds in the ICU associated with

• 66% reduction in adverse drug events (ADEs)• ADEs reduced 10.4/1000 pt days to 3.5• Prevent one ADE every 143 patients

Leape*Leape LL, Cullen DJ, et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA .1999;282(3):267-270.

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Problem Solving*

• First Order– Recovers for that patient yet does not reduce risks

for future patients– Example: You go get the supply or you make do

• Second Order– Reduces risks for future patients by improving work

processes– Example: You create a process to make sure line

cart is stocked*Tucker AL, Edmondson AC. Why Hospitals Don’t Learn from Failures: Organizational and Psychological Dynamics that Inhibit System Change. California Management Review, 2003 ;45(2):55-72.

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Improve Pain Management

1. Educate Staff2. Put VAS card at bedside3. Have residents report pain scores4. Define defect as pain score > 3.

Erdek Pronovost

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Percent of ICU Patients per Week where Pain was Measured with a

Modified VAS Scale

0%20%40%60%80%

1 2 3 4 5

Week

PDSA1

PDSA2 PDSA3 PDSA4

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Improve Pain Management

0102030405060708090

100

week 1 week 2 week 3 week 4 week 5

% with VAS < 3

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How do you know risks were reduced?

• Did you create a policy or procedure (weak)?

• Do staff know about policy or procedure?

• Are staff using the procedure as intended?– Behavior observations, audits

• Do staff believe risks were reduced?

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Summarize and Share Findings

• Summarize findings (Case Summary )

• Share within your organizations

• Share de-identified findings with others in collaborative (pending institutional approval)

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Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity.

Regular training and education, even if infrequently used, of all devices and equipment.

Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together.

Label wires and sheaths noting the appropriate partner for this device.

ACTIONS TAKEN TO PREVENT HARM IN THIS CASEThe bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together.

Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath.

Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire.

CASE IN POINT: An African American male ≥ 65 years of age was admitted to acardiac surgical ICU in the early morning hours. The patient was status-post cardiacsurgery and on dialysis at the time of the incident. Within 2 hours of admission to

theICU it was clear that the patient needed a transvenous pacing wire. The wire wasThreaded using an IJ Cordis sheath, which is a stocked item in the ICU and standardfor PA caths, but not the right size for a transvenous pacing wire. The sheath thatmatched the pacing wire was not stocked in this ICU since transvenous pacing wiresare used infrequently. The wire was threaded and placed in the ventricle and staffsoon realized that the sheath did not properly seal over the wire, thus introducing riskof an air embolus. Since the wire was pacing the patient at 100%, there was nopossibility for removal at that time. To reduce the patient’s risk of embolus, thebedside nurse and resident sealed the sheath using gauze and tape.

Safety Tips: Label devices that work together to complete a procedureRule: stock together devices need to complete a task

SYSTEM FAILURES: OPPORTUNITIES for IMPROVEMENT:

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Fellow Defect Interventions

1 Unstable oxygen tanks on beds Oxygen tank holders repaired or new holders installed institution-wide

2 Nasoduodenal tube (NDT) placed in lung Protocol developed for NDT placement

3 Medication look-alike Education, physical separation of medications, letter to manufacturer

4 Bronchoscopy cart missing equipment Checklist developed for stocking cart

5 Communication with surgical services about night coverage

White-board installed to enhance communication

6 Inconsistent use of Daily Goals rounding tool Gained consensus on required elements of Daily Goals rounding tool

7 Variation in palliative care/withdrawal of therapy orders

Orderset developed for palliative care/withdrawal of therapy

8 Inaccurate information by residents during rounds Developing electronic progress note

9 No appropriate diet for pancreatectomy patients Developing appropriate standardized diet option

10 Wrong-sided thoracentesis performed Education, revised consent procedures, collaboration with institutional root-cause analysis committee

11 Inadvertent loss of enteral feeding tube Pilot testing a ‘bridle’ device to secure tube

12 Inconsistent delivery of physical therapy (PT) Gaining consensus on indications, contraindications and definitions, developing an interdisciplinary nursing and PT protocol

13 Inconsistent bronchoscopy specimen laboratory ordering

Education, developing an order set for specimen laboratory testing

Critical Care Fellowship Program*

*Berenholtz SM, Hartsell TL, Pronovost PJ. Learning From Defects to Enhance Morbidity and Mortality Conferences. Am J Med Qual. 2009;24(3):192-5.

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Key Lessons

• Focus on systems… not people

• Prioritize

• Use safe design principles

• Go mile deep and inch wide rather than mile wide and inch deep

• Pilot test

• Answer the 4 questions

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Action Plan

• Complete staff safety assessment (repeat)

• Review the Learning from Defect tool with your team

• Select one defect per month/quarter to learn from

• Post the stories of risks that were reduced

• Share with others, in fact….

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References

• Pronovost P, Weast B, Rosenstein B, et al. Implementing and validating a comprehensive unit-based safety program. J Pat Safety. 2005; 1(1):33-40.

• Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003; 18(2):71-75.

• Pronovost PJ, Weast B, Bishop K, et al. Senior executive adopt-a-work unit: A model for safety improvement. Jt Comm J Qual Saf. 2004; 30(2):59-68.

• Thompson DA, Holzmueller CG, Cafeo CL, Sexton JB, Pronovost PJ. A morning briefing: Setting the stage for a clinically and operationally good day. Jt Comm J Qual and Saf. 2005; 31(8):476-479.