1. Patient Safety at LLUMC

2. Quality Review/RCA »16-20 per year »32 in 2012 »Variety of cases ~Medication events ~Retained foreign objects ~Sedation ~Procedure issues

3. Quality Review/RCA »Process issues, not individual error or evaluation of professional practice »Become aware via ~Electronic Event Report ~Phone call ~Conversations ~Other

4. Quality Review/RCA process »Details from source »Review records »Interview those involved »Timeline »Meet to discuss »Identify issues, determine actions

5. Swiss Cheese model

6. Case – Oxygen tank transport »The patient, a 26 week premature infant, was transported to the NICU on 4/23/05 in an open warmer by the nurse and RCP. The oxygen tank was secured to the open warmer with tape on both ends of the tank. The oxygen tank bumped into a bin located in the hallway knocking the tank off the open warmer, and inadvertently extubating the infant

7. Case – Oxygen tank transport »Policy: The infant warmers should have brackets for attaching oxygen tanks during transport. If no bracket is available, the oxygen tank should be transported in a wheeled carrier.

8. Case – Oxygen tank transport »The warmer used did not have the bracket for oxygen transport. New warmers were purchased after brackets had been installed on all existing warmers. Brackets were not installed on the new warmers. »Inspections of the warmers had not revealed the lack of brackets. Staff were aware of the problem, unknown whether it had been reported

9. Case – Oxygen tank transport Actions: ~Survey all warmers, gurneys, beds, etc. for compliance with oxygen tank transport requirements. Order brackets and install on warmers ~Re-educate staff on correct procedure ~House-wide re-education on correct procedure ~Add Oxygen tank security to Environmental Rounds checklist

10. Case – Wrong medication This 34 month old girl was in the OR for an outpatient procedure - laryngoscopy/bronchoscopy. The Anesthesia practitioner removed a vial from the Zofran bin in the Acudose for administration at the end of the case. The medication was administered prior to extubation, as usual, to prevent nausea and the child taken to the PACU(2800). The patient did not awaken as soon as expected. Another practitioner attempted to remove a dose of Zofran from the same bin, and found that there were four vials of Presodex in the Zofran bin. When this was communicated with other staff in the area, it was found that the med given to this pt was actually Presodex.

11. Case – Wrong medication Actions ~Discuss event with the techs involved, emphasizing correct behavior ~Assess current use of Fill sheet for restocking Accudose cabinets ~Evaluate restocking protocol for needed changes, and implement as appropriate ~Staff reminded of the importance of checking medication labels, not just appearance

13. Example… Cefotaxime Ceftriaxone

16. Case – Feeding tube placement

17. Actions: ~Assessment of resident abilities to interpret basic studies ~Encourage use of Radiology resident consultation for interpretation ~Work on process for 2 nd victim support ~Work on process for modifying culture – team approach, encourage calls for assistance/backup

18. Case – Wrong side procedure

19. Actions: ~Anesthesia personnel to obtain written procedural consent for all blocks, filled out by the person obtaining the consent ~Time-out process for blocks, to include the peri-anesthesia RN

20. Communication A review of QR/RCA cases showed that about 80% of the cases involved teamwork and communication issues.

21. Case – Perforated bowel

22. Actions: ~Continue to implement TeamSTEPPS ~Reinforce nursing report up chain of command ~Reinforce with residents – when called to talk with patient/family, re-assess patient to be able to speak to current situation

23. Focus for Safety »Report safety issues »Be alert to you see what you expect to see situations »Clear communication – written and verbal »Teamwork – dont be afraid to get backup, clarify, ask for help. Recognize limitations »Dont skip safety processes