1. NoCVA HEN CAUTI Campaign Learning from Defects
Shelby Lassiter, BSN, RN, CPHQ, CIC
Kathy Steele, BSN, RN
October 11, 2012

2. Polling Question 1
I am experienced in doing defect analyses (root cause analyses) and am confident analyzing CAUTI events to learn from individual events as well as several events in aggregate. TRUE FALSE

3. Polling Question 2
I know what CUSP is and am experienced in applying CUSP principles in my unit. TRUE FALSE

4. Objectives Participants will be able to:
Define CUSP and list the five steps
Define “defect.”
Describe at least one concept about why defects occur.
Describe the first step in analyzing a CAUTI as a defect.
Define “psychological safety” and describe why it is important for a thorough defect analysis.

5. The Five Steps of CUSP Educate on the Science of Safety
Identify defects (today)
Engage leadership (now and future)
Continue to learn from defects (today)
Teamwork and communication (now and future)
This chart illustrates the 5-Steps of CUSP \, which form the underlying framework for improvement in this Collaborative.
Train Staff in the participating unit(s) in Science of Safety—We reviewed the Science of Safety and how it relates to this Collaborative in last month’s webinar. Cannot over-emphasize the importance that the unit staff have some fundamental knowledge and understanding if you are going to be able to achieve desired goals. While some of this was not new for you, most staff have only a vague notion of these principles, and some training on Science of Safety needs to be undertaken in the early stages of this Collaborative. I heard a good quote from an ICP at a hospital who has sustained zero CLABSI over time. She said that…”instead if focusing on just getting to zero as your target, need to promote 0 tolerance for deviations in process”. This is how you not only achieve but sustain improvement over time. The staff on this unit need to have a fundamental knowledge of safety in order to begin this journey.
Identify defects. Have system in place for staff to report events and for leaders to learn of events. Many of you have already started doing daily huddles. Do you routinely ask “how is next patient to be harmed on this unit”; How can we prevent that harm from happening”
Engage Leadership. Most if not all of you have some form of leadership rounds taking place in your hospital and may even have an assigned executive sponsor who meets with your unit staff on a regular basis. The Executive Leader needs to be aware that the unit is participating in this Collaborative—the scope, goals and objectives—so that can provide that high level support by partnering with the unit to improve communications and educate leadership.
Continue to Learn from Defects
Use a Learning from Defects Tool to address the top risks identified by the team. This tool will help frontline providers investigate safety defects by looking at one defect, break down the factors that contributed to the defect, implement changes to reduce probability of recurrence, and summarize what was learned from this investigation. Today’s webinar will focus on this aspect of CUSP
5. Staff use tools to improve teamwork, communications, and other systems of work. (checklists, TeamSTEPPS tools, etc.). Most hospitals using some form of insertion bundle and CL checklist. Yet despite that, CLABSI’s still occurring. In upcoming webinars, will present success stories to share tools, techniques and strategies that have helped others sustain improvement. The baseline safety culture survey we are asking your units to complete will give us important information as what teamwork and communication opportunities exist among the staff.

6. What is CUSP?
Comprehensive Unit-based Safety Program Strategic framework for safety improvement that integrates communication, teamwork, and leadership to create and support a culture of patient safety that can prevent harms.
It features:
evidence-based safety practices,
staff training tools,
standards for consistently measuring harms (infection rates such as CLABSI),
engagement of leadership, and, tools to improve teamwork among health care team members.
Concept developed by Dr. Peter Pronovost at Johns Hopkins several years ago to bundle key, actionable concepts.

7. New CUSP Toolkit and Location
Now on AHRQ website
Added tools, resources such as videos

8. CUSP: Identifying and Learning from Defects
Tap into the website tools to enhance your LfD process.

9. What is a Defect ? Defect:
Any clinical or operational event or situation that you would not want to happen again. May include events that you believe actually caused harm or put patients at risk for significant harm.
Johns Hopkins’s “Learning from Defects” tool from CUSP Toolkit at . Accessed Oct 8, 2012.
We are going to go through some definitions and concepts quickly as most of this is review from the IHI Open School content.

10. Definitions Defect Analysis: Defect Prevention: Accessed April 2010.
-the process of analyzing a defect to determine its root cause.
Defect Prevention:
-the process of addressing root causes of defects to prevent their future occurrence.
Lanier K. Experiences In Root Cause Analysis and Defect Prevention Methods. Presentation publically available at
Accessed April 2010.
What’s in a name?
Defect analysis
Root cause analysis
Epidemiological investigation
May differ in some ways but all have the same core elements and are trying to answer the questions: What caused this? How do we prevent it from happening again?

11. Basic steps in the “L-from-D” Process
What happened?
Why did it happen?
How will you reduce the likelihood of it happening again?
How will you know the risk is reduced?
With whom should you share the learning?
Due to time constraints, majority of time today will be focused on Steps 1 and 2. More info to come on steps 3-5 on future collaborative and individual team calls.

12. Why bother?
Reimbursement systems are being reengineered to reward the best performers (no margin, no mission, no salary, no job…)
Growing transparency of outcomes
Defects are expensive in many ways…
Excellence in care provided - learning from each defect is the best way to prevent it from happening again
The Golden Rule-it’s what we’d want done for us or the person we love most!

13. It’s All About Prevention
Learning from defects reduces the likelihood of event occurring again and causing harm.
Learning may occur in two areas:
System design
Human behavior
Using a tool to aid learning provides structure and consistency
Learning from each CAUTI (or any type of harm) allows learning from common cause variations.
Learning from defects that might contribute to CAUTIs (any type of harm) allows prevention further “upstream” from the harm to make care even safer.
Today we’ll focus on a tool for learning from each CAUTI you have. If you are not having CAUTIs, the defect you choose to analyze may be related, such as lack or or inconsistent hygiene.

14. Background Concept #1 Normalized deviance: (Workarounds, short-cuts)
Long-term phenomenon in which individuals or teams repeatedly accept a lower standard of performance until that lower standard becomes the “norm.”
I.e. what starts out as a deviation from SOP becomes routine practice and is “normalized.” It becomes acceptable and may no longer even be recognized as deviation. (Just Culture terms for this: behavioral drift, at-risk behavior)
Allowed because we get away with it…most of the time…
Driving Example?

15. A Famous Example: Challenger Tragedy
NASA team accepted a lower standard of performance on solid rocket booster O-rings.
Got comfortable with seeing occasional O-ring damage.
By the time Challenger launched, O-ring damage was considered a marginal problem.
In 1986, O-ring damage had become an accepted normalized deviance.
On 1/28/86, Challenger exploded soon after take-off, killing all 7 crew members.
Explain what SRB O-rings do
Previous successes led to over confidence and the belief that observed problems, such as o-ring blow-by, were not serious (since it had happened many times without serious consequences).
Looked for proof that the flight would fail, rather than proof that it would succeed (i.e., success had become normal)
They concentrated on analyzing just flights where something went wrong, instead of all flights.
Pressures from the White House.
Thiokol wanted to be on good terms with NASA because of upcoming booster rocket contracts.
Avoiding appearing incompetent -- there had been several delays and cancellations already.
NASA under severe budget constraints, is concerned about losing funding.
Couldn't delay much longer without canceling (other launches scheduled), losing the teacher-in-space photo-op
The notion that you cannot control all the risks.
Attitudes towards engineers: they are perfectionists, they are not risk-takers, they always want to collect more data, and they do not see the big picture. Their input is important but if you listen to them too much you will find that you never do anything.
Astronauts were not part of the decision process, so loss of life did not loom particularly large in decision-makers' minds.

16. What are some common healthcare normalized deviances?
Inconsistent hand hygiene practices.
Not disinfecting aspiration ports on Foleys when obtaining specimens.
Using the same container to empty urine collection bags in semi-private rooms.
Hanging the Foley bag on the walker or gait belt when ambulating the patient or throwing it up on the stretcher during transport or hanging it from the side-rail.
Diapering patients with diarrhea.
What else?
What are some normalized deviances on your unit?

17. Excuses to Deviate
“The rule(s) is stupid” –May not appear to have value
Rule or reason for it is unknown – Not valued
New technology
Complexity of work
Rule does not apply to this patient
“Rule(s) doesn’t apply to me”
“I know a better way”
Healthcare worker is not the one at risk in most situations.
Competing priorities:
Cost and time,
Culture (politics, hierarchy, lack of communication openness, etc.)
“It won’t hurt anything this one time…” –Assumed or minimal consequences.
TWO MAJOR FACTORS which can drive normalized deviance in healthcare are 1) we often are not aware of the consequences (the outcome is separated in time from the deviance plus the personnel aware of/tolerating the deviance may never be aware of the consequence: e.g. lack of hand hygiene and CAUTI…the ED nurse not performing hand hygiene prior to inserting a FC may never know this patient sustained a CAUTI 2 days later and it is hard to know if one hand hygiene omission caused the infection.) and, 2) unlike airplane pilots, we do not perceive that we ourselves are the ones at risk for those consequences
Also be aware that excuses to deviate are most often non-spoken. Explore them with staff, docs, etc. and directly ask how they “feel” about a new policy/rule, etc. Help them understand the concept of normalized deviance and its contributions to errors.

18. Background Concept 2: Errors in Complex Systems
The “sharp end” refers to the personnel or parts of the health care system in direct contact with patients. Personnel operating at the sharp end may literally be holding a scalpel (eg, an orthopedist who operates on the wrong leg) or figuratively be administering any kind of therapy (eg, a nurse inserting a Foley) or performing any aspect of Foley care.
The blunt end refers to the background of policies, administrative priorities, process designs, etc. where decisions are made that impact the sharp end “downstream.”

19. Active Failures
Active failures: errors that occur at the point of contact between a human and some aspect of a larger system (e.g., a human-machine interface).
They are generally readily apparent (e.g., pushing an incorrect button, not securing a Foley) and almost always involve someone at the frontline or “sharp end”.

20. Latent Failures
Latent Failures: less apparent failures of organization or design that contribute to the occurrence of errors or allowed them to cause harm to patients.
Occurrences are at the “blunt end” but may result in active failures on the “sharp end.”
AKA: “Accidents waiting to happen.”
Reason JT. Human Error. New York, NY: Cambridge University Press; 1990.
Example: No process exists to remind nurses or physicians that a Foley is in place or due to staffing, the ED personnel have to “manage” by themselves to insert Foleys, even though the patient may not be able to cooperate with instructions or have physical issues. Foley not secured because the securement device comes packaged separately from the insertion tray There are several securement devices available, each with it’s own criteria for use and a Nurse Tech is inserting the Foley who has not been inserviced on the criteria. Latent failures are often behind active failures. Any time an active failure occurs, look for the background latent failures.

21. Swiss Cheese Model
Swiss Cheese - James Reason developed the "Swiss cheese model" to illustrate how analyses of major accidents and catastrophic systems failures tend to reveal multiple, smaller failures leading up to the actual hazard.(1) it’s a collection of small failures that lead up to a bigger one.
Complex systems fail because of the combination of multiple small failures, each individually insufficient to cause an accident. These failures are latent in the system and their pattern changes over time. With CAUTI, the smaller active and latent failures are probably the most common type. (Lack of aseptic technique for insertion, hand hygiene lapses, leaving Foley in too long, etc.) Example: A Cost Savings team in the ED in a hospital decides to stop purchasing Foley insertion kits due to cost. They priced it out and by staff gathering supplies each time a Foley is needed, they can save the hospital over $50,000 in the ED alone. (The hospital’s IP does not sit on this team.) This leads to ED staff pulling supplies in a variable fashion and impacts their ability to insert Foleys using aseptic technique plus they spend more time pulling the items together. The IP discovers this when she sees CAUTI rates spike across house and she does some walk-throughs to talk to staff.

22. The best light is often that from a burning bridge….
Background Concept 3:
Analysis of a defect should occur as soon as possible after the defect is recognized.
The best light is often that from a burning bridge….
~Don Henley
Make sure you have a system for finding out about a CAUTI as soon as it occurs. (Or other type of defect) This allows investigators to obtain better information surrounding events that are often not documented as well as better understand if there are any emotional or psychological factors going on surrounding the event. An atmosphere of psychological safety along with the opportunity for communication are essential to ensure this happens.

23. A Review: The 5 Steps in the LfD Process
What happened?
Why did it happen?
How will you reduce the likelihood of it happening again?
How will you know the risk is reduced?
With whom should you share the learning?
Due to time constraints, majority of time today will be focused on Steps 1 and 2. More info to come on steps 3-5 on future collaborative and individual team calls.

24. Tips For HAI LfDs
It is rare to find the exact source in a non-outbreak-related infection.
HAIs are usually the culmination of many infection prevention breaches. (More than one hole lined up in the Swiss cheese…)
Your job in a defect analysis is to search for the contributing factors that were most likely to have culminated in the infection in this particular patient.

25. Tip for HAIs
Learn about the organism and how it’s typically transmitted, if there has been an organism identified. Tap into your Infection Preventionist to help the group process through the chain of infection to help in search for contributing factors.
Pseudomonas aeruginosa is a free-living bacterium, commonly found in soil and water. However, it occurs regularly on the surfaces of plants and occasionally on the surfaces of animals. Members of the genus are well known to plant microbiologists because they are one of the few groups of bacteria that are true pathogens of plants. In fact, Pseudomonas aeruginosa is occasionally a pathogen of plants. However, Pseudomonas aeruginosa has become increasingly recognized as an emerging opportunistic pathogen of clinical relevance.
It is an opportunistic pathogen, meaning that it exploits some break in the host defenses to initiate an infection. In fact, Pseudomonas aeruginosa is the epitome of an opportunistic pathogen of humans. The bacterium almost never infects uncompromised tissues, yet there is hardly any tissue that it cannot infect if the tissue defenses are compromised in some manner. It causes urinary tract infections, respiratory system infections, dermatitis, soft tissue infections, bacteremia, bone and joint infections, gastrointestinal infections and a variety of systemic infections, particularly in patients with severe burns and in cancer and AIDS patients who are immunosuppressed. Pseudomonas aeruginosa infection is a serious problem in patients hospitalized with cancer, cystic fibrosis, and burns. The case fatality rate in these patients is near 50 percent.
Pseudomonas aeruginosa is primarily a nosocomial pathogen. According to the CDC, the overall incidence of P. aeruginosa infections in U.S. hospitals averages about 0.4 percent (4 per 1000 discharges), and the bacterium is the fourth most commonly-isolated nosocomial pathogen accounting for 10.1 percent of all hospital-acquired infections.
Characteristics
Pseudomonas aeruginosa is a Gram-negative rod measuring 0.5 to 0.8 µm by 1.5 to 3.0 µm. Almost all strains are motile by means of a single polar flagellum.
The bacterium is ubiquitous in soil and water, and on surfaces in contact with soil or water. Its metabolism is respiratory and never fermentative, but it will grow in the absence of O2 if NO3 is available as a respiratory electron acceptor.
The typical Pseudomonas bacterium in nature might be found in a biofilm, attached to some surface or substrate, or in a planktonic form, as a unicellular organism, actively swimming by means of its flagellum. Pseudomonas is one of the most vigorous, fast-swimming bacteria seen in hay infusions and pond water samples.
In its natural habitat Pseudomonas aeruginosa is not particularly distinctive as a pseudomonad, but it does have a combination of physiological traits that are noteworthy and may relate to its pathogenesis.
• Pseudomonas aeruginosa has very simple nutritional requirements. It is often observed "growing in distilled water", which is evidence of its minimal nutritional needs. In the laboratory, the simplest medium for growth of Pseudomonas aeruginosa consists of acetate as a source of carbon and ammonium sulfate as a source of nitrogen.
• P. aeruginosa possesses the metabolic versatility for which pseudomonads are so renowned. Organic growth factors are not required, and it can use more than seventy-five organic compounds for growth.
• Its optimum temperature for growth is 37 degrees, and it is able to grow at temperatures as high as 42 degrees.
• It is tolerant to a wide variety of physical conditions, including temperature. It is resistant to high concentrations of salts and dyes, weak antiseptics, and many commonly used antibiotics.
• Pseudomonas aeruginosa has a predilection for growth in moist environments, which is probably a reflection of its natural existence in soil and water.
These natural properties of the bacterium undoubtedly contribute to its ecological success as an opportunistic pathogen. They also help explain the ubiquitous nature of the organism and its prominence as a nosocomial pathogen.
P. aeruginosa isolates may produce three colony types. Natural isolates from soil or water typically produce a small, rough colony. Clinical samples, in general, yield one or another of two smooth colony types. One type has a fried-egg appearance which is large, smooth, with flat edges and an elevated appearance. Another type, frequently obtained from respiratory and urinary tract secretions, has a mucoid appearance, which is attributed to the production of alginate slime. The smooth and mucoid colonies are presumed to play a role in colonization and virulence.

26. Need to learn: What is organism? Is this particular organism a MDRO?
Where is it commonly found in nature?
How is it transmitted?
How common is it in your organization?
How long can it live in the environment?

27. Step 1: What Happened? Use a standard event investigation format.
No perfect form so use what is familiar and accepted that accomplishes the goal.
Must establish a chronological order of events and data related to the event.
Usually requires some research and walking the process.
The same person should not do all the research/walking the process.
Include assessment for active and latent failures.

28. Case Study Jerri, a 72 yo female was admitted for THR on 3/10/11.
A #16 Fr. Foley was placed in OR just before surgery.
On 3/10 post-op, she experienced quite a bit of pain but was otherwise stable.
Foley was due to come out on a.m. of 3/11, but her son requested it be left in to avoid having her get up to go to the BR. The Foley remained in until 3/13 a.m.
On 3/14, the patient spiked a fever to F and was pan-cultured. UA was + for LE, nitrites, and 4+ bacteria in a cathed specimen. All cultures were negative except for urine, which grew out >100,000 CFU of Pseudomonas aeruginosa. CXR was negative.

29. Pseudomonas aeruginosa
Gram negative rod.
Commonly found in soil and water.
Is frequently found on surfaces of plants and occasionally on animals.
Favors moist environments and is often found in biofilm in faucets and sink drains.
Opportunistic pathogen in humans: it exploits some type of break in host defenses to infect and rarely causes infection in healthy humans.
It is primarily a nosocomial pathogen
Reportedly colonizes more than 50% of humans.
May be highly resistant to antibiotics.
Transmitted by direct contact with a contaminated object, surface, solution, or hands.
Studies have shown it can survive on inanimate objects for up to 16 months.
In our organization, about 10% of our HAIs last year were with this organism.

32. Additional questions to consider, based on organism (examples)
What are potential sources of organism in this case?
Based on answer to A., devise rest of questions, e.g.:
Given that P. aeruginosa is found in over 50% of humans normally and it’s an opportunistic pathogen, placing a Foley put Jerri at risk of getting infected as that compromised her host defenses. Did the need for the Foley outweigh the risk of catheter-related complications, such as this CAUTI? Why do we put Foleys in all THR patients?
Were there other sources of P. aeruginosa in Jerri’s environment we need to consider? Plants? Sink? How was bathing carried out? Are bath basins used? If so, how are they cleaned after/before use? Are sinks being used as a bath basin? How is room cleaning done? Any caregivers wearing long or artificial nails?
Could it have been transmitted from another patient via healthcare workers? From the patient in the room prior to Jerri’s being there?
Etc.

33. What have we learned?
72 yo Jerri experienced a symptomatic CAUTI 4 days after FC inserted from P. aeruginosa.
FC inserted in the OR prior to surgery for THR per the circulating RN.
FC in for 3 days despite routine to remove it the day after surgery: kept in per son’s request due to patient being in pain from surgery.
No alternatives to FC considered pre-op that are documented.
Assumed pt. met insertion criteria due to type of surgery. But why do we put Foleys in all THR patients? What is the evidence to support that?
Securement device not placed in the OR. Found out it does not come in Foley kits.
No documentation of RN competency for FC insertion. RN has nursed for 30+ years and has great experience placing urinary catheters in OR but how do we know she puts them in correctly?

34. What we’ve learned so far…continued
Observed practice shows transporters are raising collection bag above level of bladder. Found they get no training in how to handle collection bags.
Pt/family engagement about FC occurred only post-op when there was deviation. Found we do not have any patient-family education materials on pre-op topics for post-op review/reiteration.
Transfer form includes only presence of FC, not date of insertion.
Hand hygiene compliance issues in OR and on unit.
Urine measurement containers are not labeled with patient name/room #.
System for reminding MDs about FCs dependent on nurse being present on rounds.
Pt. diabetic and BMI is 30.

35. Step 2: Why Did It Happen?
Review events from event report with multidisciplinary team
Further research/lit review may be necessary to determine why it happened and if there were any gaps with best practice.
Question all practices and compare to best practice defined in the literature. Don’t be afraid to really challenge practice.
For each gap identified, ask “Why” five times or until the group feels the root cause has been found. (Keep pushing to the 5 “Whys” to ensure root cause is determined and latent failures are recognized if present.)
Identify and list all contributing factors.
Prioritize contributing factors.
E.g. Alternatives to FC not considered preop. 1) WHY: FC in THR cases standard of care. 2) WHY: Some THR patients must be in bed until POD 1 and getting on/off bedpan can be painful as well as potentially harm new prosthesis in some types of procedures. Also need to closely monitor I&O in elderly post-op pt. In addition, urinary retention post-op is pretty common. 3) WHY is FC standard of care in all patients then? Some patients are dangled and weight-bear the night of surgery and with an anterior approach, have fewer mobility restrictions. Why do they need a FC in post-op? Can we evaluate each patient based on their individual situations before we say all THR cases automatically get a FC? What would that process need to look like? Also, constipation is a frequent cause of urinary retention and knowing that these patients pre-op are often on pain meds and have limited mobility, constipation is a frequent problem even before their surgery. On elective cases, could we try a bowel program the week before surgery to see if that would help? Group determines a full lit review is necessary to determine current best practice to facilitate more discussion and driving down to more specifics.

36. The Five Whys – One Example
Gap: Foley remained in 2 days longer than protocol called for.
Why 1: Son requested: He felt it was too painful for her to get OOB Why 2: Son was not aware of pain management protocol nor need for pt. to be up and moving. Why 3: Son could not be w/his mother during pre-op visits and there is no patient education on this post-op. Why 4: No process in place to reinforce critical aspects of post-op care with patients and families. Why 5: We’ve assumed patients & families remember what they were taught pre-op.
Why 1: Surgeon agreed to keep Foley in. Why 2: Surgeon felt risk of developing pneumonia greater if pt. in pain and not coughing/deep breathing post-op compared to developing CAUTI. Why 3: Surgeon did not operate here often and was not familiar with our pain management protocols. Why 4: We don’t have processes to communicate new protocols effectively. Why 5: Such communication processes are not part of protocol development.

37. How to prioritize contributing factors – an example
Importance to current event, 1 (low) to 5 (high)
Importance to future events 1 (low) to 5 (high)
Ease of Resolution 3 =easy, 2 = fairly easy
1=hard
Total Score
No process to reinforce pre-op education post-op with patients and families 5 2 12
Communication of new/revised protocols to MDs is not a formal step of protocol development/review. 1 11
Foley insertion criteria are not used with THR patients as community practice is to place a Foley in all of these patients, but w/o scientific evidence. 8
Daily review of Foley necessity is dependent upon nurses rounding with surgeons to remind them. 3 13
No process in place to assess RN competency for Foley insertion upon hire or periodically thereafter. 4

38. Step 3: How can we reduce the chances of it happening again?
Develop interventions (countermeasures) to defend against the most important contributing factors.
Then, rate each countermeasure on its ability to mitigate the root cause and on the team’s belief that the countermeasure will be executed.
Make an action plan for 2-5 of the highest scoring countermeasure.
Must have many different perspectives.
Must engage leadership.

39. Countermeasures Consider safe design principles:
Standardize – eliminate steps when possible
Create independent checklists
Learn when things go wrong (analyze defects)
Safe designs apply to technical and team work.
Brainstorm strategies and consider:
Ability to mitigate error.
Strength of countermeasures to prevent error.
Ease of implementation. (Resources and will necessary to implement.)

40. Strength of Countermeasures (Your Defensive Systems)
There are varying levels of defense strategies to defend from harm. It is critical to assess and choose the strongest defense strategy for the particular contributing factors.
Source: VA Center for Patient Safety

41. Rank Order: Strength of Error Reduction Strategies
7. Forcing functions and constraints
Designed so that errors are virtually impossible or very difficult to make.
Example: removing potassium chloride for injection from all patient care areas.
6. Automation and Computerization
Lessons human fallibility by limiting reliance on memory.
Example: Placing alcohol wipe in each Pyxis drawer with IV medications so wipe issued with each dose of medication.
5. Standardization and Protocols
Standardizes processes/materials/resources to promote awareness of evidence-based practice and increase consistency between providers. It makes defect detection possible also.
Example: Standardized CL insertion kit/cart. Standardized CL dressing change kits.
4. Checklists and double-check systems
Creates redundancies in system to look for errors
Example: Checklist to guide central line dressing changes. Requirement for an RN to recalculate doses of heparin in pediatrics behind pharmacist.
3. Rules and policies
Sets standards and expectations. Helps define what defects are.
Example: CL maintenance policy based on current science to prevent CL complications such as infection.
2. Education/Information
Education and sharing of information
Example: Staff education on CL maintenance policy.
1. Instructions to be more careful, vigilant.
Admonitions to be more careful to prevent error. This is very traditional in the mental model where individuals have total control of their actions.
Example: Management counsels an individual to “be more careful” after staff member has made a med error.
Which two do you think are most commonly used in healthcare? Education is essential and may need to be done prior to stronger countermeasure to build will and engage staff/MDs/leadership .

42. Countermeasures (interventions to reduce the risk of the defect)
“Daily review of Foley necessity is dependent upon nurses rounding with surgeons to remind them.”
Ability to mitigate the contributing factor, 1 (low) to 5 (high)
Team believes the countermeasure will be implemented and executed, 1 (low) to 5 (high)
Strength of Strategy, 1 (low) to 7 (high)
Total Score
Develop medical protocol giving nursing the ability to remove the Foley when certain criteria are met. (Nurse-driven protocol for Foley removal) 4 2 5 11
Include patient and family in daily assessment for need. 3 12
Place a reminder sticker on front of patient’s chart 1 8
For all patients with a Foley in, create a pop-up reminder on MD’s CPOE screen. 6 10

43. Step 4: How will we know the risk is reduced?
Assess outcome and process data (CAUTI rates, compliance to catheter maintenance protocols, monitoring of specific process changes, etc.)
Talk to staff to get their perspectives.
Talk to patients/families to get their perspectives.
Do gemba walks for direct observation.
Feedback from patient safety rounds.
Again, it is critical to go back to staff and talk with them.

44. Step 5: How do we communicate our findings and to whom?
Internal communications
Other units
Quality committee
Risk Manager
Staff and physicians
External communications
PSO
Collaboratives, CAUTI Campaign
Plan methods and messaging to all identified people/areas, then execute.

45. Common Pitfalls in LfD A systematic, scientific approach is not used.
Only one person does the investigation.
The medical record is the only source of information of what happened or may have happened.
Direct care providers that cared for the specific patient are not involved.
Active errors are identified but no work to push “upstream” and find the latent errors contributing to them.
Physicians and patients/families are often left out.
Team or individuals get caught in “analysis paralysis”.
Primary countermeasures stop at “re-educate” and admonishments to providers to “Be more careful.”
Learning stops at the individual defect.
Information goes no further than the team involved.

46. Carteret General Hospital

47. Carteret General Hospital

48. Carteret General Hospital

49. Your Charge
Within the next two months, use the Event Investigation tool (or your own tool) to investigate a CAUTI or a defect that may lead to a CAUTI.
Go through each of the five steps of defect analysis.
Call Shelby or Jan if you have any questions, need to talk through anything, etc.

50. Resources http://www.ahrq.gov/cusptoolkit/
(CLABSI toolkit - Chapter 6 – Hygiene)
NC Participants: Shelby Lassiter –
VA Participants: Jan Mangun –