1. © 2007 JHU Quality and Safety Research Group 1 Learning from a Defect: Team Exercise Jill Marsteller, PhD, MPP

2. Workshop Objectives Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety Program. Describe the process used to identify and eliminate system defects. List three tools or strategies used to improve teamwork and build a safety culture. State research and best practices in reducing infections, preventing central line infections, and going beyond the bundle. © 2007 JHU Quality and Safety Research Group 2

3. © 2007 JHU Quality and Safety Research Group 3

4. © 2007 JHU Quality and Safety Research Group 4 What is a Defect in Patient Care? Definition-defect A defect is any clinical or operational event or situation that you would not want to happen again. These could include incidents that you believe caused harm or put patients at risk for harm (Pronovost, P. et al., (2006) Tool tutorial: A practical tool to learn from defects in patient care Journal of Quality and Patient Safety, 32, 102-108.)

5. © 2007 JHU Quality and Safety Research Group 5 Sources of Defects Adverse event reporting systems Sentinel events Claims data Infection rates Complications How is the next patient going to be harmed

6. © 2007 JHU Quality and Safety Research Group 6 Complication, LOS, Charges* ComplicationIncreased LOS Charges Pneumothorax4 days$17,000 PE or DVT5 days$22,000 Hip Fx5 days$13,500 Respiratory failure 9 days$53,000 DT’s9 days$55,000 Post op sepsis11 days$58,000 *Miller JAMA 2003

7. © 2007 JHU Quality and Safety Research Group 7 7 System Factors Impact Safety 2.Hospital 3. Departmental 4. Work 5.Environment 6. Individual Provider 7. Task Factors 8. Patient Characteristics 1.Institutional System Failures Can Come From Many Factors in an Organization 8 Major Factors that can contribute to System Failures

8. © 2007 JHU Quality and Safety Research Group 8 Safety Efforts Focus on Harm versus errors Harm- ignorance of causality- provider level Error see provider level Proactive versus reactive

9. © 2007 JHU Quality and Safety Research Group 9 LFD: A Four-step Process The LFD Process steps 1.Answers the question: “What happened?” 2.Evaluates the defect 3.Lists specific actions needed to reduce the likelihood the defect will happen again 4.How do you know the action taken got the results you wanted?

10. © 2007 JHU Quality and Safety Research Group 10 Step 1. Answer-What happened? The Role of the investigator: –Construct a brief, concise statement of the “story” surrounding the incident. –Reconstruct the timeline of the incident or near miss –Try to “view the world” as one of those involved in the event at the time the event happened: How were those involved thinking about the problem? Why did they make the decision they made? Why did they take the course of action that was taken?

11. © 2007 JHU Quality and Safety Research Group 11 Step 2. Evaluate the defect Evaluate the defect by –Reviewing and checking all the factors that caused or negatively contributed to patient harm, –Reviewing and checking all positive factors that might have reduced or eliminated harm

12. © 2007 JHU Quality and Safety Research Group 12 Probes to Contributing Factors: Examples PatientWas the patient acutely ill? Agitated? Anxious? Aged? Language barrier? Personal or social issues? TaskWas a stated policy/protocol or guidelines followed? Were labs available for decision making? CaregiverFatigue? Lack of experience by care givers? Any physical or mental health issues with provider? TeamWere handoffs (verbal or written) clear? Was there a clearly identified team leader? Were team members hearing one another’s concerns? Training and EducationWas established protocol followed? Were caregivers knowledgeable and competent?

13. © 2007 JHU Quality and Safety Research Group 13 Probes to Contributing Factors: Examples Continued PatientWas the patient acutely ill? Agitated? Anxious? Aged? Language barrier? Personal or social issues? Information Technology Did technology create an error? Technology malfunction? Local EnvironmentWere there adequate supplies and equipment? Were there adequate human resources to care for patients and support staff? Institutional Environment Was there adequate staff (lab, pharmacy, nurses)? Other

14. © 2007 JHU Quality and Safety Research Group 14 Step 3. Create an Action Plan List specific actions to reduce the likelihood of the defect happening again. -determine who will lead the defect investigation -establish a follow-up date -measure risk reduction using either a qualitative or quantitative measure.

15. © 2007 JHU Quality and Safety Research Group 15 Step 3. Action Plan: Template Example Specific actions needed to reduce the risk of the defect? Who will lead this effort Follow-up dateHow will you know the risk to the patient is reduced? Create a specific action plan to mitigate the occurrence of this type of incident or the near miss

16. © 2007 JHU Quality and Safety Research Group 16 Step 4. How will you evaluate the impact of the intervention? 1.Develop a framework to assess the impact of the intervention. 2.What are your variables? 3.How will they be measured? 4.How long will you evaluate? Utilize your clinical experts- often your frontline staff. If they don’t view it as important or effective it unlikely to be successful

17. © 2007 JHU Quality and Safety Research Group 17 Step 4. How will you evaluate the impact of the intervention? Example: VRE reduction Developed a new policy and procedure for skin antisepsis. After education and Implementation 1.Evaluate the staff’s knowledge of the policy and procedure. 2.Is the policy and procedure being adhered to by the staff? 3.Summary of the staff’s perception of the impact of the intervention in preventing the defect?

18. © 2007 JHU Quality and Safety Research Group 18 Walk Through- Case Study 1

19. 2-5 minute debriefing between teams at change of shift or hand-offs. All staff stop and have a time-out prior to performing a procedure to discuss plan and any risks. Develop a step-by-step checklist for performing a tracheotomy; make it standard policy to perform with ICU attending present. Proper debriefing and clear procedural guidelines. Poor communication among teams. Standard policy and procedure for percutaneous tracheotomy replacement was not followed. Surgical chief’s limited knowledge of trach placement difficulty, poor trach placement skills. CASE IN POINT….. This case involves a chronically, critically ill white male over 65 years of age admitted to the ICU with a GI neoplasm. He had undergone GI surgery during this hospital admission and at the time of this adverse event was mechanically ventilated, with multiple infusions, inatropes and vasopressors. Due to failure to wean from mechanical ventilation, he underwent an uneventful percutaneous tracheostomy. During the first change of the patient’s percutaneous tracheostomy, the airway was lost, likely because the Shiley was placed in the subcutaneous tissue rather than the trachea, leading to hypoxia, hypotension, cardiac arrest and death. In reviewing the activities leading to this adverse event: (1) there was miscommunication between nursing staff and ICU team regarding the policy for trach replacement, resulting in a request for tracheostomy replacement; (2) surgical chief changed the trach after evening change of shift without adequate back-up; (3) surgical chief was unaware of patient’s worsening condition throughout the day and fellow was not aware of the planned trach change; (4) no verbal or written note given at change of shift noting difficulty of trach placement (done in OR); (5) neither the ICU attending (handling two admissions at the time) nor the surgical attending were notified of tracheostomy change in progress; (6) incorrect replacement trach tube used and inadequate positioning of patient; (7) ICU and surgical care teams failed to diagnose inadequate placement of replacement tube over red rubber catheter, attributing no EtCO2 or breath sounds to large cuff leak. Safety Tips: Team debriefings at change of shift or hand-offs. Time-outs for assessment prior to procedures. Checklist guidelines for complicated procedures. SYSTEM FAILURES:OPPORTUNITIES for IMPROVEMENT:

20. © 2007 JHU Quality and Safety Research Group 20 Case Number 2 Take a few minutes and familiarize with the case Review the investigate a defect tool. Discuss with your team

21. Workshop Objectives Describe the purpose and vision of the ICU Safe Care Initiative/Comprehensive Unit-Based Safety Program. Describe the process used to identify and eliminate system defects. List three tools or strategies used to improve teamwork and build a safety culture. State research and best practices in reducing infections, preventing central line infections, and going beyond the bundle. © 2007 JHU Quality and Safety Research Group 21