1. © 2009 On the CUSP: STOP BSI The Science of Improving Patient Safety

2. © 2009 Learning Objectives To understand that every system is designed to achieve the results it gets To know the basic principles of safe design of both technical and teamwork To understand how teams make wise decisions

4. © 2009 The Problem is Large In U.S. Healthcare system – 7% of patients suffer a medication error – Every patients admitted to an ICU suffer adverse event – 44,000- 98,000 deaths – Nearly 100,000 deaths from HAI – Approximately 30,000 deaths from CLABSI – $50 billion in total costs Similar results in UK and Australia Kohn To err is human

5. © 2009 10.5Alcohol dependence 22.8Hip fracture 40.7Urinary tract infection 45.2 Headaches 45.4Diabetes mellitus 48.6Hyperlipidemia 53.0Benign prostatic hyperplasia 53.5Asthma 53.9 Colorectal cancer 57.2Orthopedic conditions 57.7Depression 64.7Hypertension 68.0Coronary artery disease 68.5Low back pain Percentage of Recommended Care Received Condition McGlynn et al, NEJM 2003; 348(26):2635-2645 RAND Study Confirms Continued Quality Gap

6. © 2009 How Can This Happen? Need to view the delivery of healthcare as a science

7. © 2009 How Can We Improve? Understand the Science of Safety Every system is perfectly designed to achieve the results it gets Understand principles of safe design – standardize, create checklists, learn when things go wrong Recognize these principles apply to technical and team work Teams make wise decision when there is diverse and independent input Caregivers are not to blame

8. © 2009 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 Pronovost Annals IM 2004; Reason Patient suffers Venous air embolism

9. © 2009 System Factors Impact Safety Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors Patient Characteristics Institutional Adopted from Vincent

11. © 2009 Evidence Regarding the Impact of ICU Organization on Performance Physicians Nurses Pharmacists Pronovost JAMA 1999, 2002; Pronovost ECP 2001

12. © 2009 Aviation Accidents per Million Departures

13. © 2009Systems Every system is designed to achieve the results it gets To improve performance we need to change systems Start with pilot test  one patient, one day, one physician, one room

14. © 2009 Principles of Safe Design Standardize – Eliminate steps if possible Create independent checks Learn when things go wrong – What happened – Why – What did you do to reduce risk – How do you know it worked

15. © 2009Standardize

16. Line Cart Contents – 4 Drawers

17. © 2009 Eliminate Steps

18. © 2009 Create Independent Checks

19. © 2009 2 Year Results from 103 ICUs Time periodMedian CRBSI rateIncidence rate ratio Baseline2.71 Peri intervention1.60.76 0-3 months00.62 4-6 months00.56 7-9 months00.47 10-12 months00.42 13-15 months00.37 16-18 months00.34 Pronovost NEJM 2006

20. © 2009 Principles of Safe Design Apply to Technical and Teamwork

21. © 2009 Basic Components and Process of Communication Elizabeth Dayton, Joint Commission Journal, Jan. 2007

23. © 2009 % of respondents reporting above adequate teamwork ICUSRS Data ICU Physicians and ICU RN Collaboration

24. © 2009 Teamwork Tools Daily goals AM briefing Shadowing

25. © 2009 Teams Make Wise Decisions When There is Diverse and Independent Input Wisdom of Crowds Alternate between convergent and divergent thinking – Get from OR to balcony

27. © 2009 Don’t Play Man Down When you feel something say something

28. © 2009 Action Items Pick one area and reflect on the systems that predict performance – Walk and observe the process Work to standardize one process such as central line cart Pilot test it Ensure all staff know the science for improving patient safety

30. © 2009References Berwick DM. A primer on leading the improvement of systems. BMJ 1996;132:619-22. Langley G, Nolan K. The improvement guide: a practical approach to enhancing organizational performance. Hoboken, NJ: Jossey-Bass Publishers 1996. Needham DM, Thompson DM, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med 2004;32:2227-33. 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):1025-1033. Pronovost PJ, Angus DC, et al. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA 2002;288(17):2151-2162. Reason J. Managing the risks of organizational accidents. Burlington, VT: Ashgate Publishing Company, 2000.