Establishing Safety Event Analysis Team (SEAT) “turned ordinary people in to champions”

Presented at The Johns Hopkins Fifth Annual Patient Safety Summit Baltimore -June 6, 2014

Presented ByKrishnan Sankaranayanan MS, MBA, CPHQ, FASHRM

Senior Safety Officer / Tawam Hospital

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Disclosure

The presenter has nothing to disclose, nor has any commercial interest with any of those information's displayed in this presentation.

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About Tawam Hospital• Tawam is a 466-bed tertiary care facility located in the garden city Al Ain in the

middle of the desert, and one among the largest healthcare facilities in the United Arab Emirates.

• In 2006 the General Authority of Heath Services now called as the Abu Dhabi Health Services Company PJSC (SEHA) entered in to a ten year affiliation contract with Johns Hopkins Medicine.

• Tawam Hospital has current status with – Joint Commission International Accreditation (2006; 2009; 2012), – College of American Pathology (CAP; 2011) and – American College of Graduate Medical Education- International (ACGME; Program

Accreditation)

Discussion items

• Non-punitive approach to error reporting.• Culture of safety survey scores and event

reporting linkages.• Creating a process to help frontline staff

report incidents and learn lessons out of it.

Summit Theme-"In Pursuit of High ReliabilityHRO principles

• Aligns with all the five principles of high reliability1. Sensitivity to operations2. Reluctance to simplify3. Preoccupation with failure4. Deference to expertise5. Resilience

“Quote”

“The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”(Leape 2009)

Dr. Lucian Leape is a professor at Harvard School of Public Health, he is a health policy analyst whose research has focused on patient safety and quality of care

http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2Q2013.pdf

Sentinel Event Data - Root Causes by Event TypeApril 15, 2014

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Greatest Challenge at Tawam

• Employees hail from 60 nations• Hierarchies between providers • A culture that isn’t accustomed to

acknowledging medical errors.• Tendency for poor communication and

teamwork that lead to adverse events

Tawam had a history-“you made a mistake, and you’re terminated.”

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When errors occur one of the three things happen

• It can cause the person to become a championOr • It can cause the person to leave the profession

prematurely Or• It can make the person go in to a shell and feel

completely withdrawn and Disengaged.

Data source

• Culture of safety assessment surveys• Incident Reporting system• System changes initiated through

SEAT• Celebrating Safety- Staff recognition

SAQ’s 2008 & 2010 (ICU CUSP)

Safety Event Analysis Team

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Safety Event Analysis Teams- SEAT

–A team of believers & opinion builders– Team identified defects from Patient Safety

Net (PSN) – Implemented systems changes to reduce

the probability of recurring.–At least one defect was investigated each

month.

HSOPS 2012 & 2013 (ICU CUSP)

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System changes –Medication Cabinet

Verbal order carried out against policy for Narcotic medication. (Fentanyl Patch)– Analyzed usage of each Narcotic and Controlled

medication (for the previous six months).– Determined Critical/emergency need of each drug.– Reduced the inventory of the Narcotic and

Controlled by 50%. (reduced risk by half)– ICU physicians and nurses informed about the

changes.– Periodical review of the usage being carried out.

System changes – CVL pull

• Action to secure the Central Line– Implemented loop dressing to secure the

lines.–Monitored effectiveness of the system

change.–Wherever possible considered removing the

CVL.–Had no incidents thereafter.

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Staff recognition

In the picture:Iyad Mahmoud; Jainy Mathew; Lynn Petrie; Krish and Dr. Said Abuhasna

System changes -Pressure Ulcers

• 9 PU’s reported between Oct 2011 &Mar 2012– Joint investigation conducted by wound care nurse

and wound care link nurse.– Developed Nursing care plans.– Conducted one to one education. – Involved Respiratory Therapists.– Introduced

• Change in policy • BIPAP vacations• Gel masks to prevent device related PU’s.

Staff recognition -Wound care & RT

In the picture:Priya Padmanabhan; Stephanie Woodworth; Lynn Petrie; Krish and Dr. Said Abuhasna

System changes Misplaced CVL

• Patient had a central line inserted in the ED and arrived in the ICU.

• The nurse was not sure about the position of the catheter.

• ICU doctor checked the chest X-ray done in ER– showed improper position

• Found to be an arterial line.• Action:

– Post procedure X-ray to be done and the position to be confirmed prior to shifting patient.

– Post procedure VBG to be checked.

Staff recognition

In the picture:Steve CUSP Executive, Lynn Petrie; Dr. Masood and the RN Sosamma Saji

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Blood Culture Contamination Study- ICU CUSP

% Contaminated Linear (% Contaminated ) % CLSI Benchmark

Re-education and audits

Causative factors (Baseline assessment)• Improper hand washing• Improper site cleaning method prior to collection• Improper site of collection• Not adhering to PPE’s

Action• Group demonstrations• One to one staff education• Audits

Causative factors New hires lack of orientation

American Society for Microbiology & Clinical Laboratory Standards Institute benchmark for the maximum acceptable contaminated blood culture is 3%.

Re-education and auditsCreated teams for blood draws

Prevention skill fair

Causative factors Sustainability

Staff recognition

Maryan Dimaano Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for being part of the blood culture contamination reduction project.

Staff recognition

Maria Gomez Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for being part of the blood culture contamination reduction project.

Staff recognition

Lali Varghese Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for being part of the blood culture contamination reduction project.

Staff recognition

Shanthi Subramanian Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for catching a near miss medication error, that resulted in

a system change in the pharmacy.

ICU-CUSP

Jasmin Jamilan Nurse receiving the certificate of appreciation from Steve Matarelli CUSP Executive for catching a near miss medication error.

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Implications of SEAT

• The staff came open and reported the incidents• It helped institute a Fair and Just Culture• Investigation examined the processes and not just

people.• Staff share their experiences with other CUSP units. • SEAT helped turn these staff in to champions.

Broke the myth“you made a mistake, you don’t get terminated.”

Increasing trend in reporting

May 2014ICU CUSP Completed

Six Years

References

• Leape LL. Testimony, United States Congress, House Committee on Veterans' Affairs; 1997 Oct 12.

• Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32:102-108.

• Wolf, Z.R & Hughes, R.G. “Error reporting and disclosure”. In Hughes, R.G (Ed). Patient Safety and Quality. An Evidence-based handbook for Nurses. 2008; 35: 333-379.

Thank YouPatient Safety Top Priority

Patient Safety Everyone's Responsibility

Contacts:ksankara@tawamhospital.ae

+971 50 9211649