Presentation on theme: "Taking Care of Patients Safely"— Presentation transcript:
1 Taking Care of Patients Safely Pitt County Memorial Hospital
2 Let’s not learn patient safety by accident… Willie King, age 51 with a history of diabetes, consented to a have a below knee amputation on his right foot. Surgeons amputated is left foot in error.Prior to surgery, Willie joked with the medical staff, “You know which one it is, don’t you? I don’t want to wake up and find the wrong one gone.”
3 Let’s not learn patient safety by accident… Joan Faulkner was badly burned in a hospital in North Carolina when a cauterizing tool ignited the oxygen that she was receiving during a routine surgical procedure. Her top lip was burned off, her face, neck and chest suffered 2nd and 3rd degree burns.
4 The Costs of MistakesThe Institute of Medicine estimates 44,000 to 98,000 deaths occur each year due to medical errorsAn additional 100,000 deaths occur each year from hospital-acquired infections, half of which were preventableProbability of a patient dying in a hospital due to an human error is 1 in 300.
5 These types of errors can happen at any hospital!
7 From Managing the Risks of Organizational Accidents, James Reason Why Do Events Happen?Sometimes an error occurs, but an event or injury is prevented by an internal system of checksSignificantevents orinjuriesSometimes multiple errors line up to allow a significant event or injury to occurFrom Managing the Risks of Organizational Accidents, James Reason
8 Human Error Classification There are 3 major categories of errorsSkill-based errorsRule-based errorsKnowledge-based errors
9 Human Error Classification Skill-Based ErrorsErrors made when performing acts or tasks while utilizing skills on “auto-pilot”Skill-based errors most often occur during lapses in attention (e.g. when we’re pressed for time, or when the action is so routine we don’t pay attention).
10 Human Error Classification Rule-Based ErrorsErrors made when performing acts or tasks that require application of rules accumulated through experience and trainingTypes of Rule-Based ErrorsWrong RuleMisapplication of Correct RuleNon-Compliance with Rule
11 Human Error Classification Knowledge-Based ErrorsErrors made when performing acts related to new or unfamiliar situations that require problem solving or when a rule does not exist or is unknown to the performerTypes of Knowledge-Based ErrorsDecision-makingProblem solving
12 Behavior Based Expectations & Tools to Assist in the Reduction of Errors
13 Behaviors for Physicians 1. Pay Attention to DetailSelf-check using STAR2. Communicate ClearlyRepeat-backClarifying questionsPhonetic/numeric clarificationSBAR3. Handoff Effectively4. Support Each OtherSpeak-Up/Listen using AAAEncourage questions
14 BBE #1: Pay Attention to Detail Focus attention to always think before we act.Why should we do this?To avoid unintended slips or lapsesTo reduce the chance that we’ll make an error when we’re under time pressure or stressWhen should we do this?Before we act, speak, and document
15 Error Prevention Tool Self Checking Using STAR Stop:Think:Act:Review:Pause for 1 to 2 seconds to focus on what you’re about to doThink about what you’re about to do – focus on the actionConcentrate and perform the taskCheck to see if the task was done right
16 BBE #2: Communicate Clearly Communicate correct information in a timely and appropriate manner.Why should we do this?To ensure that we hear things correctly and that we understand things correctlyTo prevent avoid wrong assumptions and misunderstandings that could cause us to make wrong decisionsWhen should we do this?Whenever we communicate information – either in person or over the phone – that could affect the care and safety of a resident or an employee
17 Error Prevention Tool 3-Way Repeat Backs When information is transferred...123Sender initiates communication using Receivers Name. Sender provides an order, request, or information to Receiver in a clear and concise format.Receiver acknowledges receipt by a repeat-back of the order, request, or information.Sender acknowledges the accuracy of the repeat-back by saying, That’s correct! If not correct, Sender repeats the communication.
18 Error Prevention Tool Clarifying Questions Ask 1 to 2 clarifying questionsWhen in high risk situationsWhen information is incompleteWhen information is ambiguousWHY: To reduce the probability of making a wrong assumption. Asking clarifying questions reduces the risk by 2 1/2 times!!HOW: Phrase your clarifying questions in a positive way and in a manner that will get an answer that improves your understanding of the information
19 Error Prevention Tool Phonetic Clarifications letter followed by a word that begins with the letter. For example:For sound alike words, say the letter followed by a word that begins with the letter. For example:A AlphaB BravoC CharlieD DeltaE EchoF FoxtrotG GolfH HotelI IndiaS SierraT TangoU UniformV VictorW WhiskeyX X-RayY YankeeZ ZuluJ JulietK KiloL LimaM MikeN NovemberO OscarP PapaQ QuebecR Romeo
20 Error Prevention Tool Numeric Clarifications For sound alike numbers, say the number and then speak each digit of the number. For example:15…that’s one-five50…that’s five-zero
21 BBE #3: Handoff Effectively Handoff patients or tasks by giving appropriate information and ensuring understanding and ownership.Why do we have this behavior?To ensure that complete and accurate information about the patient, project, or task is communicated when responsibility transfers from one individual to anotherWhen should we practice this behavior?When turning responsibility for a patient, project, or task to another individual
22 Error Prevention Tool SBAR for an Effective Handoff When transitioning care to another physician, or when requesting a consult on a patient, use the SBAR technique to organize your communicationSituation: Describe the situation, patient or questionBackground: Highlight the important information, precautions, issuesAssessment: Outline your read of the situation, problems and precautionsRecommendation: State your recommendation, request or plan
23 BBE #4: Support Each Other Speak Up for Safety by using the Triple A techniqueAsk (Do you think we should order a CXR?)Advocate (I think we need to order a CXR.)Assert (I’m concerned that we may miss something if we don’t get a CXR.)TipsUse the lightest touch possible…When asserting, use the safe word: “concern”If not successful and you’re still worried, then use chain of command
24 Encourage QuestionsEncourage questions by inviting questions and positively reinforcing questions when asked.Asking a question is an emotional security issue. Foster a culture of critical thinking by encouraging questions. Invite questions, and use positive reinforcement when questions are asked.Top 3 Statements to Encourage Critical Thinking1“What do you think?”“That is an interesting question”“Let’s explore this”1 Rubenfeld, “Critical Thinking Tactics for Nursing”