1. Creating a Culture of Safety: Challenges in Ophthalmology James P. Bagian, MD, PE Director, Center for Health Engineering University of Michigan Founding Director, VA National Center for Patient Safety jbagian@umich.edu

2. Ensuring Correct Surgical Care What was the objective? What have we done? How have we done? What have we learned? What remains to be done?

3. What Was The Objective? Patient gets the best care possible Diagnose and treat as intended No inadvertent harm Incorrect surgery (aka Wrong-sided surgery) SSI/HAI/DVT

4. What Have We Done? Public & Professional Recognition of Problem NQF, Joint Commission, AAOS, AAO, etc. Guidelines, Regulations, etc. NQF Serious Reportable Events Joint Commission National Patient Safety Goals State, local, and organizational actions

5. NQF Serious Reportable Events

6. Joint Commission

10. American Academy of Ophthalmology Steps Prior to Day of Surgery “clinic and surgery areas…specific data be passed between sites via written documentation rather than verbal” Steps On the Day of Surgery “…proper eye should clearly be notated on the consent form. “ “person who marks the eye should use written documentation with verbal verification” Timeout – All team members, patient, side, implant, etc. Use “Hard Stop” if required

12. American Academy of Ophthalmology Checklist for the Surgery Chart Pre-Op Area Patient ID, Procedure, Side Eye marked Operating Room Patient ID – name and birth date Procedure & Side Proper Implant – Style and Power “Prior to draping, circulating nurse ensures that operative plan is visible (post drape) so that the surgeon can read it while gowned and gloved. “ “The circulating nurse writes the patient's name, operative eye, IOL style, and IOL power on the white board. “

13. How Have We Done? Problems still exist

14. How Have We Done? - VA 2001-2006 Experience (All Specialties) 108 OR adverse events reported Ophthalmology and Orthopedics the highest reports although not most common procedures Communication (inadequate timeout) and Patient Mis-Identification played major role Wrong side >40% Wrong Implant >30% Wrong Site/Patient/Procedure each approx. 10% Neily et al. Incorrect Surgical Procedures …Arch Surg 2009 Nov;144(11):1028-34

16. What Have We Learned? - VA Actions needed well before entering the OR Timeout period is too late in many cases Systems-based approaches beyond individual Involvement of all disciplines Structured communication that drives discussion Briefings & debriefings, Medical Team Training essential

17. Supporting Long Term Memory Checklists Put knowledge in the world vs. in the head Recognition is better than recall Checklist Philosophy “Read and Verify” checklists “Read and Do” checklists

18. Checklist-Driven Preoperative Briefing  Antibiotic Prophylaxis  DVT Prophylaxis

19. Checklist-Driven Preoperative Briefing  Antibiotic Prophylaxis  DVT Prophylaxis

20. Vertical Hierarchy “Silence Kills”. Team members uncomfortable “speaking up” when something does not seem right in a patient’s care, leading to patient harm. Poor communication between team members leading to a lack of situational awareness and a poor clinical decision resulting in patient harm. Did Medical Team Training (MTT) improve either of these baseline healthcare problems in our Organization?

21. Has MTT improved the Care of the Veteran? “Catches” in the Operating Room. Surgical morbidity and mortality.

22. Preventing Harm June 1, 2009 MTT Update: 110 facilities 144 Undesirable Events Prevented

23. Improved OR Efficiency Following MTT Following MTT... MTT Status Update June 1, 2009, 110 Facilities.

24. Nursing Turnover P = 0.02 45 Operating Rooms and 35 Intensive Care Units Pre = 12 Months Prior to Learning Session Post = 12 Months Following Learning Session

25. 25 Outcomes – Morbidity / Mortality Observed / Expected Mortality Ratios Quarters of MTT August 19, 2009 MTT Preliminary Report : N = 99 facilities. P = 0.03

26. Summary - Gaps Systems Approach – Surgical issues must be dealt with in the extended peri-operative period, not solely in the OR Entire system of care must be examined and engineered with desired results in mind – avoid unintended consequences Patient Identification Antibiotic Prophylaxis DVT Prophylaxis Implant Use Checklist-guided briefings and debriefings Can’t rely on individuals being careful (vigilant) Team Training – start in initial training & sustain More than SBAR – Leadership Must Be Involved