Patient Safety Past, Present, Future 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. 2 Definitions Patient Safety: The reduction and mitigation of unsafe acts within the healthcare 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 3 Evolution of Patient Safety ‘Will we put the methods of science to work in the evaluation of our practices, or must we admit that no matter how much we read, study, practice and take pains, when it comes to a show-down of the results of our treatment, no one could tell the difference between what we have accomplished and results of some genial charlatan…?” Codman, 1915 4 What Patient Safety Is and Is Not • It is not what most of us were thinking about 10 years ago • It is not what ‘we have always done’ • It is the most significant change in the healthcare system in over a century • It is a new applied science • It has forever changed the face of modern healthcare 5 Medical Error Citations Medical Error Citations collated by the National Patient Safety Foundation for the period 1939-98. 120 80 60 40 20 96 93 90 87 84 81 78 75 72 69 66 63 59 51 0 39 Citations 100 Year 6 Adverse Events • • • • • • • • • • • • • Delayed or missed diagnoses Medication errors Wrong side surgery Wrong patient surgery Equipment failure Patient identity Transfusion errors Mislabeled specimen Patient falls Time delay errors Laboratory errors Radiology errors Procedural error • Lost, delayed, or failures to follow up reports • Retention of foreign object following surgery • Contamination of drugs, equipment • Intravascular air embolism • Failure to treat neonatal hyperbilirubinemia • Stage lll or lV pressure ulcers acquired after admission • Wrong gas delivery • Deaths associated with restraints or bedrails • Sexual or physical assault 7 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 8 Sources of System Error Adverse Events • • • • • • • Overall culture Education/Training/Experience System design / HFE Resource availability Demand/Volume Throughput Impedance Shift-work/schedules 9 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. % Positive Responses from: Pilots Medical Is there a negative impact of fatigue on your performance? 74% 30% Do you reject advice from juniors? 3% 45% Is error analysis system-wide? 100% 30% Do you think you make mistakes? 100% 30% Easy to discuss/report mistakes? 100% 56% 10 Comparative Reliability Between Industries Difficulty with Referral PPM 1,000,000 100,000 10,000 • •• • Low Back TX 1000 100 Mammography Screening •• Tax Advice (phone-in) (140,000 PPM) • Post Heart Medication Attack Medications Accuracy in General Airline Baggage Handling Domestic Airline Flight Fatality Rate (0.43 PPM) 10 • 1 DEFECTS SIGMA 50% 1 31% 2 7% 1% 0.02% 3 4 5 Sigma Scale of Measure 0.0003% 6 11 Source: Institute for Healthcare Improvement Imagine: $15 billion in annual purchases hand-written on slips of paper The Canadian prescription drug industry 1 billion service events scheduled manually over the phone Annual diagnostic test events in Canada An industry that does not increase productivity The healthcare industry in Canada comprises almost 10% of the economy A service industry that injured 7.5% of its customers through preventable errors (30% of injuries resulting in permanent impairment, 5-10% resulting in death) Hospital care in Canada Human Factors “Health care is the only industry that does not believe that fatigue diminishes performance.” Lucian Leape 13 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 14 15 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 3.5 3.9 3 2.5 Day Night 2 1.8 1.5 1 0.5 0 0.9 1.2 Cardiac Disease Cardiac Arrest 1.9 0.9 0.4 Sepsis Time of Birth* 16 Human Factors Multitasking, Interruptions, Distractions • Humans are poor multi-taskers • Drivers on cell phones have 50% more accidents, 25% of traffic accidents are “distracted drivers” • Interruptions and distractions increase error rates • Humans need very formal cues to get back on task when interrupted and distracted Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation 17 Human Factors Inherent Human Limitations • Limited memory capacity – 5-7 pieces of information in short term memory • Negative effects of stress – error rates – Tunnel vision • Negative influence of fatigue and other physiological factors • Limited ability to multitask – cell phones and driving Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation 18 Patient Safety: Barriers to Action • Difficulty recognizing errors • Lack of information systems to identify errors • Relationship of trust with providers • Access is more urgent in Canada • Leadership turnover • Fragmentation of care delivery hampers systems thinking Patient Safety: Barriers to Action • Poor capital investment framework favours short term needs • Shortages of clinical professionals • Concern about liability • Jurisdictional conflicts • Simplistic approach to building the EHR • Culture of patient safety is lacking Systems Approach to Patient Safety Measurement and Evaluation EHR Education and Professional Development Legal/Regulatory System Changes to Create a Culture of Safety Information and Communication 21 A Systems Approach “The systems approach is not about changing the human condition but rather the conditions under which humans work.” J.T. Reason, 2001 22 Reason’s Swiss Cheese Model 23 CPSI Strategies and Activities • Adverse Event Reporting and Learning System • Root Cause Analysis • National Disclosure Guidelines • Safer Healthcare Now! 24 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. Activity to date includes: 1. The synthesis of findings on adverse event reporting and learning systems related to: • international site visits • an extensive literature search and review • a comprehensive review of applicable Canadian legislation and policy. 2. Development and circulation of a consultation paper outlining recommended options for a non-punitive national adverse event reporting and learning system so that the information can be sorted, integrated, evaluated and acted upon in a highly coordinated and timely manner. 25 The Canadian Root Cause Analysis Framework What is Root Cause Analysis? • An analytic tool that can be used to perform a comprehensive, system-system based review of critical incidents. 1 History • In January of 2005 CPSI partnered with ISMP Canada and Saskatchewan Health, to begin work on the development of the Framework. Goals of the partnership • To standardize information and processes related to RCA in Canada. • To utilize those with known expertise in use of the process and knowledge transfer of the tool to assist with the development of the framework. 1 Hoffman, C., Beard P., Greenall,J., U,D., & White, J. (2006). Canadian Root Cause Analysis Framework. Edmonton AB: Canadian Patient Safety Institute 26 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) 27 Safer Healthcare Now! Interventions 1. 2. 3. 4. 5. 6. Deploying rapid response teams Improved care for acute myocardial infarction Prevention of adverse drug effects Prevention of central line-associated bloodstream infection Prevention of surgical site infection Prevention of ventilator associated Pneumonia Retrieved from www.saferhealthcarenow.ca or www.soinsplussursmaintenant.ca Toll free#: 1-866-421-6933 28 Campaign Structure Campaign Support SHN National Steering Committee Secretariat - CPSI CIHI Clinical Support CCHSA Operations Teams Western Node Patients Canadian ICU Collaborative Peer Support Network Quebe c Node Ontario Node CAPHC Measurement Working Group & CMT IHI Atlantic Node Other Canadian Faculty ISMP Canada Education & Resource Working Group Partner Network Communication Working Group 29 West Ontario Atlantic Quebec Total Healthcare Delivery Organizations [includes hospitals, agencies, services and regions (with one or more hospitals participating)] 45 98 23 10 176 *As of January, 2007 30 Teams Continue to Enroll Saferhealthcare Overview Total # Enrolled Teams September 2005 to January 2007 600 541 579 491 500 443 403 400 296 300 200 118 100 0 Total # of Teams EnrolledTeams Sep-05 Nov-05 Mar-06 Jun-06 Aug-06 Oct-06 Jan-07 31 Ventilator Associated Pneumonia (VAP) Calgary Health Region RGH - VAP Incidence by confirmed date x Chart 50 UCL = 46.11 VAP rate (VAP cases/1000 vent days) 40 30 Mean = 10.30 20 10 Goal 8.4 LCL = 0 0 May- Jun-04 Jul-04 Aug04 04 Sep- Oct-04 Nov04 04 Dec- Jan-05 Feb04 05 Mar- Apr-05 May- Jun-05 Jul-05 Aug05 05 05 Sep05 Month 32 Ventilator Associated Pneumonia (VAP) St. Paul’s Hospital (SK) 400 350 300 250 200 150 100 50 0 Sep- 30-05 Nov-30-05 Sep-9-03 Aug-8-04 May-11-05 Jun-14-01 Mar-16-02 June -15-00 Sep-12-00 Dec-20-99 Mar-31-00 Jul-3-99 Nov-1-99 No new cases reported to date Mar-5-99 May-31-99 Number of Days between cases Days between VAP cases 229 days since last reported VAP Month VAP rate per 1000 10 8 6 VAP/1000 4 2 Month Dec Aug- Apr-05 Dec- Aug- Apr-04 Dec- Aug- Apr-03 Dec- Aug- 0 Apr-02 VAP rate per 1000 vent. days SPH Monthly VAP reports 14 12 10 8 6 Jan-Nov 4 2 0 1999- 2000- 2001- 2002- 2003- 20042000 2001 2002 2003 2004 2005 VAP rate per 1000 33 Preventing Central Line Infections COLLABORATIVE'S CUMULATIVE CRBSI RATES/1000 LINE DAYS 6 Pediatric ICU's 7.0 National Nosocomial Infections Surveillance System (NNIS) Rate 6.0 Rate per 1000 line days . 5.0 Pediatric Teams Join Canadian ICU Collaborative 4.0 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 34 Rapid Response Team University of Alberta Pre-implementation Post-implementation # Cardiac Arrests 7 (4.0 per 100 separations) 1 (0.8 per 100 separations) Total # calls ICU ALOS 10.2 6.4 24 Source: ICU Collaborative 35 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 36 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 37 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 38 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: – the key best practice approaches to patient safety – how to build a culture of safety & reporting while maintaining professional accountability – how to disclose adverse events to patients – Participants will also practice the effective communication skills and techniques when confronted with critical incidents 39 CPSI Strategies and Activities Simulation in Canada Goal: To facilitate the development of a national simulation strategy for healthcare Objectives • To create a national vehicle for the promotion and endorsement of simulation including an infrastructure for collaboration • To endorse team – focused simulation education Phases Phase 1: Endorse and Support Phase 2: Educate Phase 3: Evaluate 40 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 41 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 42 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. 43 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 Dates: September 24-28, 2007 Location: The Kingbridge Centre, Toronto, Ontario 44 Other Important Tools • Resource Crew Management Briefings • S-B-A-R – Situation – Background – Assessment – Recommendation 45 Patient Safety Is It Getting Better? 46 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) 47 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 48 Much has Been Done … Trend in Age-Adjusted 30-Day In-Hospital Death Rate Excludes NL, QC, BC 49 What Does Average Mean? (Results from Baker/Norton) Deaths among patients with preventable adverse events Extra hospital days associated with adverse events 50 Efforts to Date (Preliminary based on data as of March 2006) > 3,200 more lives saved between Apr 04-Dec 05 vs. 03/04 51 But Variations Persist Distribution of HSMR for facilities with at least 2000 discharges, FY 2004/05 – Adapted international method 30 Number of Facilities 25 20 15 10 5 0 41-60 61-70 71-80 81-90 91-100 101-110 111-120 121-130 131-140 141-150 151-160 HSMR 52 Human Error – the New View The point of an investigation is not to find where people went wrong. It is to understand why their assessments and actions made sense at the time. Sidney Dekker (2002); The Field Guide to Human Error Investigations 53 Human Error – the New View HUMAN ERRORS ARE SYMPTOMS OF DEEPER TROUBLE Sidney Dekker (2002); The Field Guide to Human Error Investigations 54 55 56 Conclusion Safe and Reliable Organizations • Accept that accidents are inevitable and failure will occur • Accept that impact of failure can be minimized • Promote a safety culture • Listen to and support front-line workers • Establish a framework that recognizes costs of failure and benefits of reliability • Involve managers in communicating overall picture 57 Conclusion Safe and Reliable Organizations • Train managers to recognize and respond to system abnormalities • Become adaptive – learn quickly and efficiently from adverse events • Make knowledge about problems available throughout organization • Design redundancy to create more opportunity to detect and correct • Avoid shaming, blaming and organizational hubris • Don’t micro-manage – allow decision migration - Croskerry, EPSS Nov 2006 58 Conclusion Seven Steps to Patient Safety 1. 2. 3. 4. 5. 6. 7. Lead and support your staff Foster a culture of safety Promote reporting Involve patients and the public Implement solutions to reduce / avoid harm Learn and share safety solutions Integrate your safety management activity Adapted from: National Patient Safety Agency for the National Health Service “Seven Steps to Patient Safety – An Overview Guide for NHS Staff” 59 “Culture eats strategy for lunch over & over again” Marc Bard 61 High Reliability Organizations are Pre-occupied with the Possibility of Failure “…there are some patients we cannot help, there are none we cannot harm...” Arthur Bloomfield, M.D. Quality of Healthcare in America Project 2003 -----Dr. Ken Stahl
