Patient safety is the cornerstone of high-quality healthcare services. In the presentation, A summary of the frameworks & practical approaches to improve safety of patient care.

1. Dr. Manal Elsayed Abdelaziz
B.Sc. Pharm, CPPS, CPHQ, CLSSBB, DTQM 1

2. Learning Objectives
Explore frameworks
& practical
approaches to
improve safety of
patient care
Understand the
analysis of system
failures &
accountabilityDescribe systems
thinking & evolution
of patient safety
culture
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3. Breaking The Wall of Silence
Donald Church, 49 years old
male had a tumor in his
abdomen.
When he left the hospital, the
tumor was gone but a metal
13-inch-long retractor had
taken its place by mistake!
Josie King, 18 months old little
girl was hospitalized for 2nd
degree burns.
2 weeks into successful
recovery, Mom noticed signs of
intense thirst and lethargy, but
was assured the vital signs and
monitors indicated all systems
“normal”.
Josie arrested & was
resuscitated, but had suffered
irreversible brain damage and
died
Betsy Lehman, 39 years old
female suffered from breast
cancer, was given (26 grams)
four times the intended dose (6.5
grams) of a potent
chemotherapy drug over 4 days
period during a stem cell
transplant.
She was close to being
discharged when she suddenly
died!
3

4. Patient safety: making health care safer, World Health Organization, 2017 http://www.who.int/iris/handle/10665/255507
• If medical error was a disease, it would be the third leading cause
of death in the United States.
• In the United Kingdom, one incident of patient harm is reported
every 35 seconds (on average)
• In a study on frequency and preventability of adverse events,
across 26 low- and middle-income countries, the rate of adverse
events was around 8%, of which 83% could have been prevented
and 30% led to death. Approximately two-thirds of all adverse
events happen in low- and middle-income countries.
• The most common adverse safety incidents are related to surgical
procedures (27%), medication errors (18.3%) and health care-
associated infections (12.2%)
Patient Safety
Making health care safer
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5. •‫أن‬ ‫سابق‬ ‫وقت‬ ‫في‬ ‫الصحي‬ ‫المجال‬ ‫في‬ ‫خبراء‬ ‫كشف‬ ‫فقد‬25,900‫سنوات‬ ‫خمس‬ ‫خالل‬ ‫المملكة‬ ‫في‬ ‫ارتكب‬ ‫قد‬ ‫طبي‬ ‫خطأ‬-
‫عام‬ ‫بين‬ ‫ما‬2001-2006‫م‬-.
•‫األخ‬ ‫نسبة‬ ‫أن‬ ‫إلى‬ ‫صحفية‬ ‫تقارير‬ ‫أشارت‬ ‫آخر‬ ‫جانب‬ ‫من‬‫طاء‬
‫الحك‬ ‫المملكة‬ ‫مستشفيات‬ ‫في‬ ‫ارتكبت‬ ‫التي‬ ‫الطبية‬‫ومية‬
‫بلغت‬ ‫بنسبة‬ ‫ارتفعت‬ ‫قد‬ ‫واألهلية‬86%‫الخمس‬ ‫خالل‬
‫الماضية‬ ‫سنوات‬..‫ب‬ ‫المتعلقة‬ ‫القضايا‬ ‫عدد‬ ‫بلغ‬ ‫فيما‬‫األخطاء‬
‫ا‬ ‫في‬ ‫الطبية‬ ‫الشرعية‬ ‫الهيئات‬ ‫نظرتها‬ ‫والتي‬ ‫الطبية‬‫لرياض‬
‫حوالي‬ ‫فقط‬ ‫وجدة‬6851‫قضية‬..‫بلغت‬ ‫الذي‬ ‫الوقت‬ ‫في‬
‫شكاوى‬ ‫عليهم‬ ‫أقيمت‬ ‫الذي‬ ‫الصحيين‬ ‫الممارسين‬ ‫نسبة‬‫نتيجة‬
‫الماضي‬ ‫العام‬ ‫خالل‬ ‫طبية‬ ‫أخطاء‬2242‫أطباء‬ ‫مابين‬
‫تخدير‬ ‫وأخصائيي‬ ‫وممرضين‬
•60%‫الوالدة‬ ‫أثناء‬ ‫طبية‬ ‫أخطاء‬ ‫تخص‬ ‫القضايا‬ ‫من‬
5

6. How Hazardous is Health Care?
Total#ofDeaths
100K
1K
100
10K
1
# Encounters /Fatality
Health Care
Bungee Jumping
1K10 100 10K 100K 1M 10M
Mountain Climbing
Driving
Chemical Manufacturing
Chartered Flights Nuclear Power
European Railroads
Scheduled Airlines
Hazardous
(>1/1000)
Ultra-Safe
(<1/100,000)
Total#ofDeaths/Year
100K
1K
10
100
10K
Regulated
R. Amalberti, L. Leape et al. Violations and migrations in healthcare: a framework for understanding and management. Qual. Saf. Health Care. 2006 December; 15(suppl 1): i66-i71

7. STOP
7

8. Institute of Medicine’s (IOM)
Call to Action - December 1999
44,000 – 98,000 Death / Year
Equivalent to
1 Jumbo Jet / Day
$29
Billion /
Year
8

9. 9
We are young – but we are making progress!
• To Err Is
Human
• Crossing
The
Quality
Chasm
1999/2001 2002/2003
• Never
Events
List
• NPSGs
2004/2005
• Hospital
compare
• Unannoun
-ced
Survey
2007/2008
• Keystone
Project
• 5 Million
Lives
Campaign
2011
• The
Concept of
Meaningful
Use
2015
• Free
From
Harm
Report.
2005/2006
• 100,000 Lives
Campaign
• TeamSTEPPS
for healthcare

10. Healthcare - Complex Adaptive
System
• Systems are composed of multiple,
interacting components: people,
machines, processes, and data.
• Difficult if not impossible to predict
behavior of the system based on a
knowledge of its components.
• Increased complexity = increased
chance of something going wrong!
Why do interns make prescribing errors? A qualitative study MJA 2008: 188 (2): 89-94
Ian D Colombes, Danielle A Stow Asser, Judith A Colombes and Charles Mitchell
10

11. The Manchester Patient Safety Framework (Masa), NHS, 1st Jan.2006
11
Pathological
Why waste
our time on
safety?
Reactive
We do
something
when we
have an
incident
Bureaucratic
We have
systems in
place to
manage all
identified risks
Proactive
We are always
on the alert for
the risks that
might emerge
Generative
Risk
management
is an integral
part of
everything we
do

12. Incident Reporting System -
OVR
‘Good reporting is the cornerstone of patient safety. Safety cannot be improved
without a range of valid reporting, analytical and investigative tools that identify the
sources and causes of risk in a way that leads to preventative action.’
Martin Fletcher,
Chief Executive at the National
Patient Safety Agency
12

13. 13

14. Punitive Culture
All errors are due to
individual performance
Individuals are blamed
based on the outcome
Transparency is
impossible
All errors are due to
system failures
No individual
accountability
It couldn’t be afforded
Cultivating Dynamic Patient Safety Environment
No-Blame Culture
Marx D. Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York: Trustees of Columbia University in the City of New York, Columbia
University; 2001.
Optimally Supports A System of
Safety Regardless The Outcome
Zero Tolerance for Reckless Behavior
Just
Culture
14

15. Swiss Cheese Model for Accident
Trajectory
Medication isn’t prepared by the
same nurse administering it
Not counter check the
medication order or sign the
care given on bedside
Improper patient identification using
patient name & room number
Nurse prepares
to administer a
medication for a
patient
Improper
communication
between staff
Wrong patient
receives wrong
medication
After J. Reason
15

16. Generic Error Modelling
System - GEMS
16
Unsafe
Acts
Intended Action
Unintended Action
Memory Failures
Violation
Mistake
Lapse
James Reason, Human Error
Slip
Basic Human Error Types
Attentional Failures
Rule-Based Mistake
Knowledge-Based Mistake
Routine Violations
Exceptional Violations
Acts of sabotage
Skill-Based Error

17. The Three Behaviors in Just Culture
Reckless
Behavior
Conscious disregard of
substandard &
unjustifiable risk
Manage through:
• Remedial action
• Disciplinary action
At-Risk
Behavior
Choice of risk believed to
be insignificant or
justified
Human
Error
Inadvertent product of
our current
system design
Manage through changes in:
• Processes
• Procedures
• Training
• Design
• Environment
Console Coach Punish
Manage through:
• Removing incentives for
at-risk behaviors
• Creating incentives for
healthy behaviors
• Increasing situational
awareness
Managing for Safety Using Just Culture, Outcome Engineering, Dallas, TX, www.outcome-eng.com, copyright 2005 17

18. Professional Accountability
Pyramid
18

19. Human Factors Engineering -
User Centred Design
• Human factor engineering ( Ergonomics) is about designing the workplace & the
equipment in it to fit capabilities & limitations of human performance.
• We don’t redesign humans; we redesign the system within which humans work.
• One definition of “human error” is “human nature”! Even for experienced
professionals! Let’s not make it more difficult / unsafe for them …
• Human factors engineering
o Can save lives
o Improve safety & quality of service
o Improve user acceptance & satisfaction
o Improve reputation
o Reduces the overall costs
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20. Poor Communication Complacency
Lack of
Knowledge
Distraction
Stress
Lack of
Resources
Lack of
Assertiveness
Lack of
Teamwork
Fatigue
Accepting
the Norms
Loss of
awareness
Pressure
20

21. 21
Physicians-in-training working traditional
>24-hour on-call shifts;
• Suffer decrements in performance
commensurate with those induced by a blood
alcohol level of 0.05 to 0.10%
(beyond the legal limit to drive)
• Report making 300% more fatigue-
related medical errors that lead to a
patient’s death

22. 22
Is it safe?!

23. 23
To Better Is Human

24. Care Bundles
• “ A bundle is a structured way of improving the processes of care and patient
outcomes: a small, straightforward set of practices — generally three to five —
that, when performed collectively and reliably, have been proven to improve
patient outcomes.”
Institute of Healthcare Improvement
• Care bundles aim to ensure application of all interventions is consistent for all
patients at all times.
• Examples of bundles:
o Ventilator-Associated Pneumonia (VAP) Care Bundle
o Catheter-Associated Urinary Tract Infection (CAUTI) Care Bundle
o Central Line-Associated Bloodstream Infection (CLABSI) Care Bundle
http://www.ihi.org/topics/bundles/Pages/default.aspx
24

25. TeamSTEPPS
Agency for Healthcare Research and Quality (AHRQ)
Strategies and Tools to Enhance
Performance and Patient Safety
• TeamSTEPPS® is an evidence-based teamwork
system aimed at optimizing patient outcomes by
improving communication and teamwork skills
among health care professionals.
• Based on teamwork principles identified in Crew
Resource Management (CRM) & High Reliability
Organizations (HRO’s)
• Developed by Department of Defense's Patient
Safety Program in collaboration with the Agency for
Healthcare Research and Quality.
25

26. TeamSTEPPS
Communication
SBAR
Check-Back
Call Out
Leadership
Brief
Debrief
HuddleSituation Awareness
Mutual Support Task Assistance
Conflict Resolution
Two Challenge Rule
CUS
DESC
o Valued purpose & shared vision
o Common measurable goals
o Clear roles and responsibilities
o Shared mental model, mutual trust & respect
o Engagement in extensive discussions getting
everyone a chance to contribute even the
introverts
o Conflicts are well managed & Criticism is
constructive and oriented toward removing
obstacles & problem solving
o Effective team leadership that shifts from
time to time, as appropriate, to drive results.
No individual members are more important
than the team
High-Performing Teams
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27. SBAR
• It is a structured communication model for providing patient information. It
ensures complete information transfer & provides the receiver a structure to
remember the informed details, especially critical ones that requires immediate
attention and action.
o S=Situation – what is happening? (identify yourself, the resident, and the problem)
o B=Background – what is the background? (history, vitals, results, etc)
o A=Assessment – what do I think the problem is? (findings, severity, life- threatening?)
o R=Recommendation – what would I recommend? (what is next?, needs, timeframe)
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28. SBAR
Mrs. Hana is having
increasing dyspnea &
is complaining of
chest pain
She had total knee
replacement 2 days ago. 2
hours ago, She began
complaining of chest.
HR=120, BP=128/54,
restless & short breath.
She may be having a
cardiac event or a
pulmonary embolism
I recommend that
you see her
immediately & Start
O2 stat
Dr. Ahmed, This is RN.
Nada A. Abdelaziz,
calling about your patient
Hana Ahmed Abdallah,
MRN 20001745
S B A
R
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29. Brief & Debrief
Brief & debrief is a strategy for sharing the plan & evaluate performance. To reduce
medical errors by getting everyone briefly discuss the event after it occurs. It’s
conducted in a safe, non-threatening manner that frames mistakes as learning
opportunities.
Brief
Who is on core team?
All members understand
and agree upon goals?
Roles and responsibilities
understood?
Plan of care?
Staff availability?
Workload?
Available resources?
Debrief
Communication clear?
Roles and responsibilities understood?
Situation awareness maintained?
Workload distribution?
Did we ask for or offer assistance?
Were errors made or avoided?
What went well, what should change, what
can improve? 29

30. CUS
• Used to get someone‘s immediate attention and
only when appropriate urgent situation.
o I’m Concerned about my resident’s condition
o I’m Uncomfortable with my resident’s condition
o I believe the Safety of the resident is at risk
• If the safety issue is not acknowledged,
a supervisor should be notified.
I am Concerned that
Mrs. Sara isn’t her usual
self. I’m Uncomfortable
that she is behaving
oddly. I believe she is
not Safe; she may have
something serious going
on that we’re missing
Stop The Line!
30

31. Comprehensive Unit-based
Safety Program (CUSP)
• CUSP is a five-step program designed to change a unit’s
workplace culture by empowering staff to assume
responsibility for safety in their environment.
• CUSP is designed to:
o Improve patient safety awareness and systems thinking
at the unit level
o Investigate and learn from defects and improve
teamwork and safety culture
o Create a patient safety partnership between executives
and frontline caregivers
What Is CUSP? Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/cusp/cusp-success/whatiscusp.html 31

32. CUSP
• A multidisciplinary team is assembled to initiate CUSP activities, providing
diverse and comprehensive view of unit work systems.
• Team shall include CUSP champions & meetings are facilitated by CUSP coach in
presence of a senior hospital executive.
• Open and honest communication among all unit members is the key to success.
• The more frequent executive visits are associated with improved culture.
there appears to be a dose-dependent improvement relative to the number of
executive visits.
• Executives typically spend 9 to 12 months with a unit before rotating to another
unit, and departmental leaders move in to fill the executive role.
32

33. S B A
R
1. Educate everyone in the Science of Safety
2. Identify defects
By safety assessment survey asking; how the next patient may be harmed and how this
can be prevented beside unit scores from hospital annual culture assessment, near misses
& reported errors by unit staff
3. Recruit executive as active CUSP team member
Helps to prioritize unit safety hazards, holds them accountable for learning from defects,
and ensures they have resources and political support to implement interventions
4. Learn from one defect per month/quarter using structured tool answer these questions: What
happened? Why did it happen? What can be done to prevent this event in the future? How
will you know it worked?
By group consensus, the team members shall prioritize and choose safety issues &
develop action plans
5. Implement improvement to improve their performance (e.g., communication, teamwork,
coordination and management of patients)
CUSP Steps
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34. Key Takeaways
• Accept that accidents are inevitable and impact of failure can be minimized
• Promote patient safety culture
• Be advocate of our patients
• Teamwork makes the dream work
• Listen to and support front-line staff
• Identify & respond quickly to system abnormalities
• Spread & share the safety solutions
• Become resilient & learn efficiently from adverse events
• Avoid shaming, blaming & organizational hubris
• Integrate the safety activity into your routine work
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