RACHEL ZASTROW, RN, MSN, CPPS

BETTER, FASTER, SAFER:

APPLYING HUMAN

FACTORS AND PATIENT

SAFETY PRINCIPLES TO

CRITICAL CARE

AACN, June 2015

LEARNING OBJECTIVES

• To describe Safety Science Basics: Swiss cheese model, safety current state in US

• Verbalize Human factors engineering basics and examples.

• Verbalize method of investigating unexpected or undesirable events.

• Describe case study for CLABSI prevention.

• Identify root causes in simplified real-world example.

• Discussion of real-world elements of CLABSI bundle and how to ensure good engineering and compliance.

SAFETY IN U.S. HEALTHCARE

• In 1999 The Institute of Medicine estimated that 98,000 people died annually in hospitals due to medical error

• In 2013 this number was revised to 210,000-440,000

• The equivalent of a jumbo jet crashing every day for a full year

We are NOT getting better!

ELEMENTS OF PATIENT SAFETY ERRORS

• Inherently unreliable human beings

Operating within

• Unreliable processes and systems

Caring for

• Medically fragile patients, with limited capacity to recover from errors

ERRORS WHAT IS A LATENT ERROR?

http://psnet.ahrq.gov/primer.aspx?primerID=10

WHY SO MANY ERRORS?THE SWISS-CHEESE MODEL

Adapted from James Reason, Managing the Risks of Organizational Accidents (1997)

EVENTS ofHARM

Safety strategies

designed to stop errors

The HOLES represent

problems with the safety strategies

MEDICATION ADMINISTRATION

EVENTS ofHARM

Bar code scanning

Automated dispensing cabinet

tracking

Pharmacist

order review

Electronic

MAR

What are the safety strategies?

What are the holes in the strategies?

1. Poor wireless

connectivity

2. Med won’t scan

3. Emergency situation

4. No scanner

available

5. Scanner battery

dead

6. RN chooses not to

scan

Human FactorsWHAT IS HUMAN FACTORS?

• The science of

understanding the properties

of human capability

• The application of this

understanding to the design

and development of systems

Let’s see how many key words you can pick up…..

WHAT IS HUMAN FACTORS? INTUITIVE WORK PROCESSES

Our challenge…

To design work processes that make it easy to

do the right thing

Healthcare Performance Improvement 2014

LABELING AND PACKAGING

Which Label is Safer?

SCOPE OF HUMAN FACTORS

HUMAN FACTORS PROPOSITION #1:

STOP BLAMING EVERYTHING ON “HUMAN ERROR”

THE PROBLEM IS SYSTEM DESIGN

HUMAN FACTORS PROPOSITION #2:

WORKAROUNDS AND VIOLATIONS PROVIDE

USEFUL INFORMATION

Wonder why your hand hygiene compliance rate is stagnant? HUMAN FACTORS PROPOSITION #3:

RESISTANCE TO CHANGE IS A SYMPTOM

Improving patient safety (and other outcomes) requires a systems approach

HUMAN FACTORS PROPOSITION #4:

IMPLEMENTING WELL DESIGNED AND WELL-

INTEGRATED TECHNOLOGY IS SMART

YOUR CHALLENGE:

WELL DESIGNED?

APPLYING HUMAN FACTORS

TO THE REAL WORLD…

A COMMON ICU PROBLEM

WHAT YOU NEED TO KNOW BEFORE ANY PATIENT SAFETY OR QUALITY IMPROVEMENT WORK

• The purpose of all QI work is to uncover latent and

active errors, with the purpose of correcting the system!

• The purpose is not, nor should it be, focused on targeting an individual.

THE SITUATION

• Mr. Jones has been diagnosed with a CLABSI in the intermediate care unit.

• First infection in over 12 months.

• Board has committed to elimination of healthcare acquired infections

• Long periods of success and literature indicates that virtual elimination is possible.

• Mr. Jones diagnosed with Sepsis

• ICU X 2 weeks, IMCU X 1 week before + blood cultures

• Comorbidities include

• Diabetes

• Age (78)

How will we figure out what happened?

WHAT IS A ROOT CAUSE ANALYSIS?

• Not a single unified process, but a collection of tools and knowledge that facilitates use of data and information about processes to interpret problems within a system with the goal of preventing future

harm.

RCA OUTLINE

• Gather information through applying tools and knowledge [Conduct high-quality RCA]

• Organize data and information about processes

• Interpret problems within a system

• Take Steps to prevent future harm

RCA OUTLINE

• Plan: Gather information through applying tools and knowledge

• Do: Organize data and information about

processes

• Study: Interpret problems within a system

• Act: Take Steps to prevent future harm

Learn more about IHI’s Model for Improvement at http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx

RCA TOOL

Benefits

• Most complete picture

• Lends itself to group

discussion

• Leads to deeper questions

about the system

• Helps team prepare fully for

RCA meeting

Disadvantages

• Relies on high quality team

performance

• Tool Execution

• Improvement activities

• Still requires some inference

and judgment

• Can miss important

contributors if not done correctly, or if relevant team

members missing

Uses pre-formulated questions to examine many aspects of

events.

RCA TOOL – GETTING STARTED

• Clinicians are best for conducting (Nicolini, Waring, &

Mengis, 2011)

• The clinicians involved in the actual event should not

be involved in completing RCA (Nicolini, et al., 2011;

“Six ways to improve your root cause analysis,” 2014)

• RCA team should include clinician representatives

from each discipline or department involved

• Review tools before interviewing involved parties.

• Conduct interviews carefully; be mindful of second

victim syndrome.

• Best first question: “What happened?”

RCA TOOL – GETTING STARTED

• Remember the purpose of your

investigation is to improve the system.

Share this with anyone you interview.

• Make a commitment and a plan to share

the results of the RCA with any involved

party.

• Initial meeting includes process map/

timeline of the event, especially if

complex.

RCA TOOL – GETTING STARTED

�Interviews with involved clinicians

complete

�Clinician representatives from each

discipline and/or department present for

RCA meeting

�Event timeline agreed upon by team

RCA TOOL - EXAMPLE

Analysis Question Prompts Root Cause Analysis Findings

Root cause

Plan of Action

What human

factors contributed

to the outcome?

Discuss staff-related

human performance

factors that contributed to

the event.

Examples may include,

but are not limited to:•Boredom•Failure to follow established

policies/procedures •Fatigue

•Inability to focus on task•Inattentional blindness/ confirmation bias

•Personal problems•Lack of complex critical

thinking skills•Rushing to complete task

•Substance abuse •Trust

Memory lapse

may have led to missed

dressing changes, [leaving the

dressing in place for over 10 days during

the stay] because there is no memory

aid for this process.

Y Y

The human

factor in this case is memory lapse.

Note the

absence of judgment and action plan in

the root cause statement.

RCA TOOL - EXAMPLE

Analysis Question Prompts Root Cause Analysis Findings

Root cause Plan of Action

How did the equipment

performance affect the outcome?

Consider all medical equipment

and devices used in the course

of patient care, including AED

devices, crash carts, suction,

oxygen, instruments, monitors,

infusion equipment, etc. In your

discussion, provide information

on the following, as applicable:

•Descriptions of biomedical

checks

•Availability and condition of

equipment

•Descriptions of equipment with

multiple or removable pieces

•Location of equipment and its

accessibility to staff and patients

•Staff knowledge of or

education on equipment,

including applicable

competencies

•Correct calibration, setting,

operation of alarms, displays,

and controls

The patient showered while

the central line was in place with the standard

semi-permeable dressing, which

may have allowed contamination of

the site, because there was no process to safely

shower with a central line in place.

Y Y

RCA TOOL - EXAMPLE

Analysis Question Prompts Root Cause Analysis Findings

Root cause (Y/N)

Plan of Action

To what degree was

the communic-ation

among participants adequate

for this situation?

Analysis of factors related to communication should include

evaluation of verbal, written, electronic communication or

the lack thereof. Consider the following in your response, as

appropriate:•The timing of communication of key information

•Misunderstandings related to language/cultural barriers,

abbreviations, terminology, etc.•Proper completion of internal

and external hand-off communication•Involvement of patient, family

and/or significant other

Nurses did not request removal of the

unnecessary central line after the

vasopressors were discontinued (days 2-

20) because the staff feel physicians would react negatively,

The checklist for daily

communication was not being consistently

used, because the expectation to use the checklist has

lessened over time.

Y Y

ROOT CAUSE STATEMENTS

• Statements of FACT, not opinion

• Do not focus on person, but on situation

• Are clearly related to the event

• Should include“because”

RCA – HOW TO

• You probably will find more root causes than you have time to correct!

• Some findings may have regulatory implications and must be corrected.

• Choose the most relevant causes to address

• Most relevant ≠ Easiest

THE SITUATION

• Mr. Jones has been diagnosed with a

CLABSI in the intermediate care unit.

• First infection in over 12 months.

• Board has committed to elimination of

healthcare acquired infections

• Long periods of success and literature indicates that virtual elimination is possible.

• Mr. Jones diagnosed with Sepsis

• ICU X 2 weeks, IMCU X 1 week before + blood

cultures

• Comorbidities include diabetes, age (78)

ACTIONS TO ADDRESS RCA

FINDINGS

Weaker

Stronger

Strategy

Policy and Procedure

Training/ Re-training

Risk perception

Recovery

Redundancy

Forcing function/

Barrier

ACTIONS TO ADDRESS RCA FINDINGS

Strategy Example

Policy and Procedure

Write a policy about how to properly connect a tube feeding

Training/ Re-training

Educate staff about tube feeding administration

Risk Perception Tell staff about risk of accidental connection; relate actual story

Recovery Charge RN checks TFs hourly

Redundancy Require a double check when connecting a tube feeding

Forcing function/ Barrier

Ensure TF connectors cannot be accidentally connected to IVs

RCA TOOL - EXAMPLE

Root Cause Action Outcome Measurement

By…

Memory lapse re: dressing change

Investigate involvement of IVT in reminders or

dressing changes

100% of central lines will have dressing

changes every 7 days

7/01

Pt showered with

semi-permeable dressing

Investigate

options for temporary occlusive

dressings with products

Occlusive

shower dressing identified, purchased,

disseminated

8/01

SMART: Specific, Measureable, Achievable, Relevant, Time-limited.

RCA TOOL - EXAMPLE

Root Cause Action Outcome

Measurement

By…

Staff feel physicians would react negatively

to request for line removal

Improve safety culture

organization-wide through

MDs to share collaborative

safety stories with staff at each staff meeting

beginning

8/01

Checklist for daily communication is not being consistently used

Unit staff to ensure adequate supplies and access to

forms; RCA staff to share with other departments

All nursing units in the hospital will be randomly

audited for 3 months to verify use of checklists.

8/01

SMART: Specific, Measureable, Achievable, Relevant, Time-

limited.

DISCUSSION/ QUESTIONS

• Given what you know about CLABSI root causes, what are most likely to be difficult to do for fallible humans?

• How might you apply what you learned about human factors to improve the likely failures?

• Example: Line insertion cart, blood draw kits that

include ETOH wipes.

DISCUSSION/ QUESTIONS

• Can you think of a problem you’d like to dissect with an RCA? Start with an actual negative outcome or a near miss.

• Why start with near miss?

• Proactive use of RCA can help find gaps before harm occurs. Other tools might be used, but RCA is simple,

you know how to do it now, and can elicit the kind of information needed to improve the system

RESOURCES

http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/

Joint commission RCA Action Plan

Nicolini, J., Waring D., & Mengis, J. (2011). The challenges of undertaking root cause analysis in health care: a qualitative study. Journal of Health Services Research & Policy, 16 (Suppl 1) 34-41.

"6 Ways to Improve Your Root Cause Analysis." Healthcare Risk Management. AHC Media L.L.C. 2013. Retrieved March 02, 2014 from HighBeam Research: http://www.highbeam.com/doc/1G1-340759899.html

RESOURCES

http://psnet.ahrq.gov/primer.aspx?primerID=10

Patient Safety Primer: Root Cause Analysis

http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html

http://www.ihi.org/knowledge/Pages/HowtoImprove/default.aspx

IHI Improvement model