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Learning From Defects. Slide 2 Learning Objectives To Understand the difference between first order and second order problem solving To understand how.

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Presentation on theme: "Learning From Defects. Slide 2 Learning Objectives To Understand the difference between first order and second order problem solving To understand how."— Presentation transcript:

1 Learning From Defects

2 Slide 2 Learning Objectives To Understand the difference between first order and second order problem solving To understand how to address each of the 4 questions in learning from mistakes – What happened, why, what will you do to reduce risk, and how do you know it worked

3 Slide 3 Problem Solving* First Order Recovers for that patient yet does not reduce risks for future patients Examples: You do get the supply or you make due Second Order Problem Solving Reduces risks for future patients by improving work processes Example: you create a process to make sure line cart is stocked *Anita Tucker

4

5 What is a Defect? Anything you do not want to have happen again

6 Slide 6 Sources of Defects Adverse event reporting systems Sentinel events Claims data Infection rates Complications Where is the next patient going to be harmed?

7 Slide 7 4 Questions to Learn from Defects What happened? – From the view of the person involved Why did it happen? What will you do to reduce the chance it will recur? How do you know that you reduced the risk that it will happen again?

8 Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity. Regular training and education, even if infrequently used, of all devices and equipment. Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together. Label wires and sheaths noting the appropriate partner for this device. ACTIONS TAKEN TO PREVENT HARM IN THIS CASE The bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together. Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath. Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire. CASE IN POINT: An African American male 65 years of age was admitted to a cardiac surgical ICU in the early morning hours. The patient was status-post cardiac surgery and on dialysis at the time of the incident. Within 2 hours of admission to the ICU it was clear that the patient needed a transvenous pacing wire. The wire was Threaded using an IJ Cordis sheath, which is a stocked item in the ICU and standard for PA caths, but not the right size for a transvenous pacing wire. The sheath that Matched the pacing wire was not stocked in this ICU since transvenous pacing wires are used infrequently. The wire was threaded and placed in the ventricle and staff Soon realized that the sheath did not properly seal over the wire, thus introducing risk of an air embolus. Since the wire was pacing the patient at 100%, there was no Possibility for removal at that time. To reduce the patients risk of embolus, the bedside nurse and resident sealed the sheath using gauze and tape. Safety Tips: Label devices that work together to complete a procedure Rule: stock together devices need to complete a task SYSTEM FAILURES: OPPORTUNITIES for IMPROVEMENT:

9 Slide 9 What Happened? Reconstruct the timeline and explain what happened Put yourself in the place of those involved, in the middle of the event as it was unfolding Try to understand what they were thinking and the reasoning behind their actions/decisions Try to view the world as they did when the event occurred Source: Reason, 1990;

10 Slide 10 Why did it Happen System (Latent) Failures Source: Reason, 1990; Arise from managerial and organizational decisions (or lack of decisions) that shape working conditions Often result from production pressures Damaging consequences may not be evident until a triggering event occurs

11 Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects….. Their part is that of adding the final garnish to a lethal brew that has been long in the cooking. James Reason, Human Error, 1990

12 Slide 12 Why did it Happen? 12 Develop lenses to see the system (latent) factors that lead to the event Often result from production pressures. Damaging consequences may not be evident until a triggering event occurs. Source: Reason, 1990;

13 Slide 13 System Factors Impact Safety Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Institutional Adopted from Vincent

14 Slide 14 System Failure Leading to This Error Catheter pulled with Patient sitting Communication between resident and nurse Lack of protocol For catheter removal Inadequate training and supervision Patient suffers Venous air embolism Pronovost Annals IM 2004; Reason

15 Slide 15 What will you do to reduce the risk of it happening again Prioritize most important contributing factors and most beneficial interventions Safe design principles – Standardize what we do Eliminate defect – Create independent check – Make it visible Safe design applies to technical and team work

16 Factor Importance in current event 1 low to 5 high Importance in future events 1 low to 5 high

17 Slide 17 What will you do to reduce risk Develop list of interventions For each Intervention rate – How well the intervention solves the problem or mitigates the contributing factors for the accident – Rates the team belief that the intervention will be implemented and executed as intended Select top interventions (2 to 5) and develop intervention plan – Assign person, task follow up date 17

18 Slide 18 Rank Order of Error Reduction Strategies Forcing functions and constraints Automation and computerization Standardization and protocols Checklists and double check systems Rules and policies Education / Information Be more careful, be vigilant

19 Slide 19 How do you know risks were reduced? Did you create a policy or procedure (weak) Do staff know about policy or procedure Are staff using the procedure as intended – Behavior observations, audits Do staff believe risks were reduced

20 Slide 20 Summarize and Share Findings Summarize finds – 1 page summary of 4 questions – Learning from defect figure Share within your organizations Share de-identified with others in collaborative (pending institutional approval)

21 Unit Environment: availability of device. The appropriate size sheath for a transvenous pacing wire was not a stocked device. Pacing wires and matching sheathes packages separately… increases complexity. Regular training and education, even if infrequently used, of all devices and equipment. Infrequently used equipment/devices should still be stocked in the ICU. Devices that must work together to complete a procedure should be packaged together. Label wires and sheaths noting the appropriate partner for this device. ACTIONS TAKEN TO PREVENT HARM IN THIS CASE The bedside nurse taped together the correct size catheter and wire that were stored in the supply cabinet. In addition, she contacted central supply and requested that pacing wires and matching sheaths be packaged together. Knowledge, skills & competence. Care providers lacked the knowledge needed to match a transvenous pacing wire with appropriate sized sheath. Medical Equipment/Device. There was apparently no label or mechanism for warning the staff that the IJ Cordis sheath was too big for the transvenous pacing wire. CASE IN POINT: An African American male 65 years of age was admitted to a cardiac surgical ICU in the early morning hours. The patient was status-post cardiac surgery and on dialysis at the time of the incident. Within 2 hours of admission to the ICU it was clear that the patient needed a transvenous pacing wire. The wire was Threaded using an IJ Cordis sheath, which is a stocked item in the ICU and standard for PA caths, but not the right size for a transvenous pacing wire. The sheath that Matched the pacing wire was not stocked in this ICU since transvenous pacing wires are used infrequently. The wire was threaded and placed in the ventricle and staff Soon realized that the sheath did not properly seal over the wire, thus introducing risk of an air embolus. Since the wire was pacing the patient at 100%, there was no Possibility for removal at that time. To reduce the patients risk of embolus, the bedside nurse and resident sealed the sheath using gauze and tape. Safety Tips: Label devices that work together to complete a procedure Rule: stock together devices need to complete a task SYSTEM FAILURES: OPPORTUNITIES for IMPROVEMENT:

22 Slide 22 Examples of where this was applied CUSP program on ICUs Critical Care Fellowship Program Morbidity and Mortality Conferences

23 DefectInterventions Fellow 1Unstable oxygen tanks on bedsOxygen tank holders repaired or new holders installed institution-wide Fellow 2Nasoduodenal tube (NDT) placed in lungProtocol developed for NDT placement Fellow 3Medication look-alikeEducation, physical separation of medications, letter to manufacturer Fellow 4Bronchoscopy cart missing equipmentChecklist developed for stocking cart Fellow 5Communication with surgical services about night coverage White-board installed to enhance communication Fellow 6Inconsistent use of Daily Goals rounding toolGained consensus on required elements of Daily Goals rounding tool use Fellow 7Variation in palliative care/withdrawal of therapy orders Orderset developed for palliative care/withdrawal of therapy Fellow 8Inaccurate information by residents during roundsDeveloping electronic progress note Fellow 9No appropriate diet for pancreatectomy patientsDeveloping appropriate standardized diet option Fellow 10Wrong-sided thoracentesis performedEducation, revised consent procedures, collaboration with institutional root-cause analysis committee Fellow 11Inadvertent loss of enteral feeding tubePilot testing a bridle device to secure tube Fellow 12Inconsistent delivery of physical therapy (PT)Gaining consensus on indications, contraindications and definitions, developing an interdisciplinary nursing and PT protocol Fellow 13Inconsistent bronchoscopy specimen laboratory ordering Education, developing an orderset for specimen laboratory testing

24 Slide 24 Learning from Defects in M&M Conference Select 1 or 2 meaningful cases Invite everyone who touches the process including administrators Summarize event Identify hazardous systems Close the Loop (issue, person, F/U) Share what you learn

25 Slide 25 Key Lessons Focus on systems not people Prioritize and Use Safe design principles Go mile deep and inch wide rather than mile wide and inch deep Pilot test Learn form one defect a quarter Answer the 4 questions

26 Slide 26 Action Plan Review the learning from Defect tool with your team Review one defects in your unit Select one defect per month to learn from Consider using in morbidity and mortality conferences Post the stories of risks that were reduced Share with others Explore learning state wide (eg pager list)

27 Slide 27 References Bagian JP, Lee C, et al. Developing and deploying a patient safety program in a large health care delivery system: you can't fix what you don't know about. Jt Comm J Qual Improv 2001;27: Pronovost PJ, Holzmueller CG, et al. A practical tool to learn from defects in patient care. Jt Comm J Qual Patient Saf 2006;32(2): Pronovost PJ, Wu Aw, et al. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Int Med 2004;140(12): Reason J. Human Error. Cambridge, England: Cambridge University Press, Vincent C. Understanding and responding to adverse events New Eng J Med 2003;348: Wu AW, Lipshutz AKM, et al. The effectiveness and efficiency of root cause analysis. JAMA 2008;299:


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