Patient Safety 101 for Physicians Resident Core Curriculum Retreat - - PowerPoint PPT Presentation

Patient Safety 101 for Physicians

Resident Core Curriculum Retreat March 5 & 7, 2012 Partners Patient Safety Leaders

Outline

• Brief Introduction and Objectives
• Background and details of safety reporting
• Video
• Break into groups and discuss video
• Closing Thoughts
• Brief Q+A
• Please feel free to ask a question at any point in the presentation

Objectives

• View errors and near misses as a “systems problem”
• Explain why safety reporting is important to quality

healthcare, and how you can help

• Provide you with instructions on how to file a safety report
• Provide you the patient safety contact information at your

specific institution

• We want to encourage you to participate in Patient Safety

activities

• A 2008 Joint Commission report showed that physicians reported
• nly 1.1% of total safety events
• At Partners that average is 5%

Institute of Medicine’s First Quality Report: To Err is Human – November 1999

Preventable Lapses in Safety

• 44,000 to 98,000 Americans die each year
• Eighth leading cause of death in the United States
• Annual cost as much as $29 billion annually
• IOM conclusion: the majority of these problems are

systemic, not the fault of individual providers

How Can You Contribute To Patient Safety?

Simple strategy to follow:

• Identify and report events, near misses, and errors
• Near Misses constitute 70% of safety reports at Partners

and are instrumental in affecting change before there is harm to a patient

• An unreported error cannot be investigated
• Perform these improvements

Unfortunately, it’s not so simple….

Why Is There Under-Reporting?

• Culture of blame
• Medicine and society have tended to fault the person, not the

system

• Health care providers have concern for personal

consequences

• Malpractice
• Reputation
• Tedious to report
• Providers are busy
• Not a priority

Ways To Improve Increase Overall Reporting

• First, need to create a culture of safety, similar to the

aviation industry

• Move beyond blaming and punishing and towards improving

the system

• Reduce fear of reporting
• Show people safety reporting makes a positive impact
• Simplify reporting (e.g. online or call to risk

management)

• Provide feedback to reporters
• Prompt reporting (reminders, interviews, multi-

disciplinary focus groups)

Safety Reporting System

Examples of Event Types

Telling the Story

Systems Approach to Error

• Analyze the system for contributing factors that allow

errors to occur

• Vast majority of errors are due to faulty systems
• Blaming individuals is not going to prevent future errors

from occurring

• Individuals are trying to do their best
• Goal to streamline and build safeguards into systems

Contributing Factors to Error

• Systems factors
• Staff experience
• Staffing levels
• Supervision
• Policies and procedures
• Handoffs
• Workflow
• Environmental factors
• Distractions
• Noise
• Precautions
• Interruptions
• Human factors
• Judgment
• Communication
• Teamwork
• Stress
• Fatigue
• Patient factors
• Language issues
• Knowledge deficit
• Fear
• Disease acuity

The Swiss Cheese Model of System Accidents

J.Reason, J.Reason, BMJ BMJ 2000;320:768 2000;320:768-

• 770

770

Questions to Ask

• What happened?
• Were the steps in the process followed as designed?
• What steps were involved or contributed to the event?
• Where did the process break down?
• Were environmental factors relevant to the outcome?
• Were there communication issues?
• Were there equipment issues?
• Were there training or competency issues?
• Were there appropriate policies and procedures?
• Who can we bring together to come up with a systems

solution?

Video…

Case Outcomes

• Beginning of video up to the OR scene- the infant was

born with Apgar scores of 0 and suffers from profound cerebral palsy with an approximate life expectancy of 10- 12 years

• OR scene- the mother was admitted for an elective C-
• Section. She suffered an anoxic brain injury due to a

difficult intubation died 5 weeks later. Her baby was fine

• Medication error scene- the baby suffered some mild

seizures but had no other clinical sequela. The second victim, the nurse, is believed to have left the nursing profession as the result of the emotional impact of the event

Debrief

• Contributing factors
• Systems
• Environmental
• Human
• Patient
• Improvement action

Closing Thoughts

• Punishing does not prevent future errors
• If you feel that there has been retribution for reporting safety

issues, you can contact your Department Quality/Safety chair and or you Patient Safety Department for assistance.

• Think systems
• Submit at least 1 Safety Report in the next year
• Adverse events
• Near misses
• Your suggestions and ideas for systems

improvements are important!

HMS Fellowship in Patient Safety and Quality

• Contact
• Director- Tejal Gandhi, MD, MPH
• Fellowship Contact is Grace Bommarito
• 781-433-3764 or gbommarito@partners.org
• Fellowship Details
• http://www.hms.harvard.edu/hfpsq/
• 2 year postgraduate program funded by CRICO
• 5 fellows a year, each based at one of the Harvard Affiliated

sites

• MGH, BWH, Partners, BIDMC, DFCI, Children’s, and Mount Auburn
• 80% of time dedicated to operational quality/safety improvement

projects

• Optional Harvard MPH

Other Ways To Get Involved

• Center for Expertise in Quality and Patient Safety
• Safety electives/Research/Committees/Project involvement
• Safety reporting/case analysis/root cause analyses
• For Trainee Opportunities contact Jennifer Goldsmith
• jgoldsmith@partners.org
• www.partners.org/coe
• Meet Jennifer at the noon lunch table today!!!

Contacts

• BWH- Allen Kachalia and Karen Fiumara
• FH- Christi Barney and Joanne Locke
• MGH- Cyrus Hopkins and Lela Holden
• DFCI- Saul Weingart and Deborah Duncombe
• NSMC- Martha Page
• NWH- Barbara Lightizer, Bert Thurlo-Walsh, and

Marjorie Blundon

• McLean- Gail Tsimprea
• SRH- Mary O’Quinn
• PHS- Tejal Gandhi and Frank Korn