Dallas, TX November 2–4, 2012 Improving Outcomes through Patient Safety Initiatives Patricia A. Patrician, PhD, RN, FAAN Associate Professor and Donna Brown Banton Endowed Professor University of Alabama at Birmingham Birmingham, AL Acknowledgement: Many slides came from American Association of Colleges of Nursing and Quality and Safety Education for Nurses Project, funded by the Robert Wood Johnson Foundation, PI: Linda Cronenwett, PhD, RN

Dallas, TX November 2–4, 2012 Improving Outcomes through Patient Safety Initiatives Session Code: 105 Contact Hours: 0.8 CRNI Units: 2 Please use session code shown above when completing your speaker evaluation and CE form. Return the evaluation to the registration desk or receptacles located outside meeting rooms at the end of the day. Handouts for this session are available online at Session recordings will also be available post-meeting courtesy of B.Braun Medical/Aesculap Academy. As a courtesy to both presenters and attendees, please turn off all cell phones and refrain from talking during the session. Tonight’s Event: Industrial Exhibition and Networking Reception 3:30-5:30pm

Dallas, TX November 2–4, 2012 Outline Overview: Patient safety and quality improvement National initiatives Infusion safety Additional resources

Dallas, TX November 2–4, 2012 “First Do No Harm” (1:37 min.) (CATHLEEN F. CROWLEY and ERIC NALDER, HEARST NEWSPAPERS)

Dallas, TX November 2–4, 2012 Betsy Lehman (1995) Received 4X Cytoxan dose for four days “If this can happen at a place like Dana- Farber, a nationally respected institute, what is happening in other places?” –Dr. Michael Colvin, Duke U. Comprehensive Cancer Center

Dallas, TX November 2–4, 2012 Lewis Blackman (2000) eo.php?qsen_a_Lewis_Blackman_Story.f4v (6.44 minutes) eo.php?qsen_a_Lewis_Blackman_Story.f4v

Dallas, TX November 2–4, 2012

Josie King (2001) (13.33 minutes)

Dallas, TX November 2–4, 2012 To Err is Human Beginning in 2000, the Institute of Medicine released a series of reports that brought attention to the issues of quality. The first, To Err is Human brought startling statistics to light about the number of needless deaths and injuries caused by medical errors. Annual deaths AIDS ,516 Breast cancer ,297 Motor vehicle accidents ,458 Medical Errors ,000

Dallas, TX November 2–4, 2012 Crossing the Quality Chasm The second report, Crossing the Quality Chasm, provided a definition and aimed to improve quality of care. In this report, the Institute of Medicine defined quality as: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.

Dallas, TX November 2–4, 2012 Crossing the Quality Chasm Crossing the Quality Chasm established six aims that have formed a framework for moving forward with improving quality. The aims are that care should be: SafeCare should be as safe for patients in healthcare facilities as in their homes. TimelyPatients should experience no waits or delays in receiving care and service. EffectiveThe sciences and evidence behind healthcare should be applied and serve as the standard in the delivery of care. EfficientCare and service should be cost-effective, and waste should be removed from the system. EquitableUnequal treatment should be a fact of the past; disparities in care should be eradicated Patient centered The system of care should revolve around the patient, respect patient preferences, and put the patient in control.

Dallas, TX November 2–4, 2012 Subsequent IOM Reports Reports are free electronically – at least read the executive summaries!

Dallas, TX November 2–4, 2012 Minimize risk of harm to patients and providers through both system effectiveness and individual performance. Requires understanding of the complexity of care delivery, the limits of human factors, safety design principles, characteristics of high reliability organizations, and patient safety resources. - QSEN/American Association of Colleges of Nursing, 2009 Patient Safety

Dallas, TX November 2–4, 2012 Science of the interrelationship between humans, their tools and the environment in which they live and work So that systems and products can be built to enhance performance. Can be used to reduce adverse events and errors by identifying how and why systems break down and how and why human beings mis- communicate. Goal is to provide better designed systems and processes by: –Simplifying processes –Standardizing procedures –Providing backup when humans fail –Improving communication –Redesigning equipment –Understanding behavioral, organizational and technological limitations that lead to error. (WHO, 2009). Human Factors Engineering

Dallas, TX November 2–4, 2012 Health care services are provided within a complex and technological setting that is prone to accidents. When systems fail, it is due to multiple faults that occur together. Human error is one of the greatest contributors to accidents (active error); however… Latent errors or system failures pose the greatest threat to safety in a complex system. Need to shift from emphasis on active errors to one on latent errors and fix the system, not the person. Why Human Factors

Dallas, TX November 2–4, 2012 Organizational factors –Poorly designed equipment –Lack of appropriate communication –Fearful environment Work setting factors –Unworkable procedures –Inadequate or inaccessible equipment –Storage of supplies Unsafe acts –Not following procedural guidelines –Hurried, stressed staff –Work-arounds for work setting and organizational factors Latent Condition Pathways Hazards Accident Defense s

Dallas, TX November 2–4, 2012 Anatomy of a Near Miss Intact defenses Failed defenses

Dallas, TX November 2–4, 2012 Anatomy of an Error Latent failures - conditions that lead to failures – hidden; not readily apparent; an accident waiting to happen. Active failures – the “last straw”; the apparent error. Latent failure Active failure Failed or absent defenses Organizational influences Unsafe supervision Preconditions for unsafe acts Unsafe acts Mishap

Dallas, TX November 2–4, 2012 While delivery of healthcare is extremely complex and there are tremendous systems challenges, nurses often have been held accountable for harm to patients even while they have not had input into system designs and have little understanding of how complex systems leave them vulnerable to making errors. -QSEN/American Association of Colleges of Nursing, 2009 Nurses and Patient Safety

Dallas, TX November 2–4, 2012 Within a culture of safety, when an adverse event occurs, the focus is on what went wrong, not who is the problem. A culture of blame has been pervasive in healthcare. The focus has often been to try to determine who has been at fault and, all too often, to mete out discipline. –This approach leads to hiding rather than reporting errors and is the antithesis of a culture of safety. Culture of Safety vs. Culture of Blame

Dallas, TX November 2–4, 2012 Elements of a culture of safety in an organization are establishment of safety as an organizational priority, teamwork, patient involvement, openness/transparency and accountability (Lamb, 2003). There are shared core values and goals, non-punitive responses to adverse events and errors, and promotion of safety through education and training. Culture of Safety

Dallas, TX November 2–4, 2012 A safety culture requires strong, committed leadership, and engagement and empowerment of all employees. It entails periodic assessment of the culture and relationship between the organization culture and the quality and safety within the organization. Culture of Safety

Dallas, TX November 2–4, 2012 The IOM described 9 categories that provide opportunities to improve patient safety. IOM Recommendations

Dallas, TX November 2–4, 2012 Approaches include making things visible so the user is able to see actions possible at any time. Use constraints and forcing-functions (makes it hard to do the wrong thing and easier to do the right thing). 1. User-centered design

Dallas, TX November 2–4, 2012 Standardizing and simplifying procedures and tasks decreases the demand on memory, planning, and problem-solving. The use of protocols and checklists reduces reliance on memory and serves as a reminder for the steps to be followed. Simplifying processes minimizes problem- solving. Having the usual dose of a medication as the default in an electronic order entry. Purchasing equipment that is easy to use and maintain are examples of simplification of processes. 2. Avoid reliance on memory

Dallas, TX November 2–4, 2012 Work hours, work- loads, staffing ratios, distractions, and counterclockwise shift changes all affect patient safety. 3. Attend to work safety

Dallas, TX November 2–4, 2012 Checklists, well- designed alarms, rotating staff and breaks decrease the need for remaining vigilant for long periods. Look-alike medications should be stored far apart. 4. Avoid reliance on vigilance

Dallas, TX November 2–4, 2012 Training programs for effective interprofessional communication and collaboration include transitions in care and hand- offs. Introduction of new processes and technologies depends on a chain of involvement of frontline users and the need for pilot testing before widespread implementation. 5. Train for teamwork

Dallas, TX November 2–4, 2012 Patients and families should be in the center of the care process. 6. Involve patients in their care

Dallas, TX November 2–4, 2012 Reorganization and organization-wide changes result in new patterns and processes of care. 7. Anticipate the unexpected

Dallas, TX November 2–4, 2012 Errors will occur despite the best of planning. Designing and planning for recovery will allow reversal or make it hard to carry out irreversible critical functions. 8. Plan for service recovery

Dallas, TX November 2–4, 2012 Information for decision making needs to be available at the point of care. This includes easy access to drug formularies, evidence-based practice protocols, patient records, laboratory reports, and medication administration records. 9. Improve access to timely, accurate information

Dallas, TX November 2–4, 2012 Quality Improvement Quality and Safety Education for Nurses (QSEN) defines quality improvement as: Use of data to monitor the outcomes of care processes and use of improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems (Cronenwett et al., 2007).

Dallas, TX November 2–4, 2012 Quality Improvement: Another Definition "...the combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, educators – to make changes that will lead to better patient outcomes (health), better system performance (care), and better professional development (learning)." – Batalden, P. & Davidoff, F. (2007). What is "quality improvement" and how can it inform health care? Quality and Safety in Health Care, 16(1), 2-3.

Dallas, TX November 2–4, 2012 Improving Care Requires problem identification: –systematic process of defining problems –to identify potential causes of those problems –and develop strategies to improve care. Requires measurement

Dallas, TX November 2–4, 2012 Institute for Healthcare Improvement (IHI) AIM MEASUREMENT CHANGES

Dallas, TX November 2–4, 2012 Problem Identification Routine monitoring Sentinel event or observation To better understand the problem: –Cause and effect diagrams (“fishbone” or “Ishikawa”) –Process flow maps –Root cause analysis –Failure Mode and Effect Analysis

Dallas, TX November 2–4, 2012 Root Cause Analysis (RCA) From thinkreliability. com

Dallas, TX November 2–4, 2012 Identify the underlying causes of why an incident occurred So that the most effective solutions can be identified and implemented. It's typically used when something goes wrong (sentinel events) What's the problem? Why did it happen? Series of WHY’s What will be done to prevent it? Uses process maps, fishbones, and others See TapRoot®: RCA

Dallas, TX November 2–4, 2012 Documents current knowledge and actions about the risks of failures, for use in continuous improvement. Used during design to prevent failures. Later it’s used for control, before and during ongoing operation of the process. Ideally, FMEA begins during the earliest conceptual stages of design and continues throughout the life of the product or service. Failure Mode and Effect Analysis (FMEA)

Dallas, TX November 2–4, 2012 Selecting Measures Measure things that matter to patients, providers Measure things you can change (actionable): what do you (or your team) “own”? Measure close to what you are after –Temporally (time-wise): close to patient encounter –Operationally (content-wise): close to your theoretical definition. If nursing sensitive outcome is your concept, and patient adverse events are your theoretical terms, is mortality a good measure? Measure at the correct level – hospital, unit, day, shift Measure as objectively as possible – self-reports versus pill counts

Dallas, TX November 2–4, 2012 Selecting Measures Measure things for which you have (or can get) comparisons Select a balanced set of measures (structure-process- outcomes) Measure things for which you already collect data Select standardized and tested measures if possible (e.g., National Quality Forum (NQF); National Database of Nursing Quality Indicators (NDNQI); Collaborative Alliance for Nursing Outcomes; CALNOC); Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators: Consider ease of data collection, especially if you are not actually collecting the data.

Dallas, TX November 2–4, 2012 Instituting Change 1.Establish sense of urgency 2.Create guiding coalition 3.Develop vision and strategy 4.Communicate change vision 5.Empower broad based action 6.Generate short term wins 7.Consolidating gains and producing more change 8.Anchoring new approaches in the culture Kotter, J. (1996). Leading Change.

Dallas, TX November 2–4, 2012 National Initiatives Agency for Healthcare Research & Quality (AHRQ) National Quality Forum (NQF) Centers for Medicare and Medicaid Services (CMS) Institute for Healthcare Improvement (IHI) Quality and Safety Education for Nurses (QSEN)

Dallas, TX November 2–4, 2012 Agency for Health care Quality & Research (AHRQ) Lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans As 1 of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of health care services Research funding opportunities, data collection and reporting, data sources for research, clinical practice guidelines, consumer healthcare information

Dallas, TX November 2–4, 2012 Safety and quality: Reduce the risk of harm by promoting delivery of the best possible health care. Effectiveness: Improve health care outcomes by encouraging the use of evidence to make informed health care decisions. Efficiency: Transform research into practice to facilitate wider access to effective health care services and reduce unnecessary costs. Great collection of useful tools and other resources on web site AHRQ Focus

Dallas, TX November 2–4, 2012 National Quality Forum (NQF) Promotes change through development and implementation of a national strategy for health care quality measurement and reporting.

Dallas, TX November 2–4, 2012 Nursing Sensitive Measures – NQF Definition Nursing-sensitive performance measures are processes and outcomes - and structural proxies for these processes and outcomes (e.g., skill mix, nurse staffing hours) - that are affected, provided, and/or influenced by nursing personnel, but for which nursing is not exclusively responsible. Nursing-sensitive measures must be quantifiably influenced by nursing personnel, but the relationship is not necessarily causal. The NQF Report details 12 voluntary, NQF-endorsed consensus standards for nursing-sensitive care, including evidence-based nursing-sensitive performance measures, a framework for measuring nursing-sensitive care, and related research recommendations. This is the first-ever set of national standardized performance measures to assess the extent to which nurses in acute care hospitals contribute to patient safety, healthcare quality, and a professional work environment (NQF, 2012).

Dallas, TX November 2–4, 2012 NQF - 12 NSC-1 Death Among Surgical Inpatients with Treatable Serious Complications NSC-2 Pressure Ulcer Prevalence (Hospital-Acquired) NSC-3 Restraint Prevalence NSC-4 Patient Falls NSC-5 Falls with Injury NSC-6 Catheter-Associated Urinary Tract Infections (UTI) for Intensive Care Unit (ICU) Patients NSC-7 Central Line Catheter-Associated Blood Stream Infections for ICU and Neonatal Intensive Care Unit (NICU) Patients NSC-8 Ventilator-Associated Pneumonia for ICU and NICU Patients NSC-9 Skill Mix NSC-10 Nursing Care Hours per Patient Day NSC-11 Voluntary Turnover NSC-12 Practice Environment Scale-Nursing Work Index (PES-NWI) Appendices

Dallas, TX November 2–4, 2012 Centers for Medicare and Medicaid Services (CMS) In order to receive Medicare and Medicaid reimbursement, hospitals and other health care organizations must meet certain standards or “conditions of participation” Health Care Financing Administration (HCFA) Increasing requirements for reimbursement in hospitals

Dallas, TX November 2–4, 2012 Creating a Sense of Urgency: “Never Events” Recent rules established by CMS have identified “never events,” which are serious and costly events that should never occur in a hospital if appropriate care is provided. All nurses should be aware of information available from regularly collected data. For instance, all hospitals collect data related to infections, 30-day readmissions, pressure ulcers, and others.

Dallas, TX November 2–4, 2012 “Never Events” and Hospital Reimbursement Hospitals no longer get paid for the costs of certain Never Events, because they are preventable and should never happen to patients.

Dallas, TX November 2–4, 2012 Institute for Healthcare Improvement (IHI) Motivating and building the will for change; Identifying and testing new models of care in partnership with both patients and health care professionals; and Ensuring the broadest possible adoption of best practices and effective innovations Great educational resource: IHI Open School

Dallas, TX November 2–4, 2012 IHI Open School for Health Professionals Interprofessional educational community that gives students the skills to become change agents in health care improvement. Skills like quality improvement, patient safety, teamwork, leadership, and patient-centered care. Employers are looking for these skills, and patients expect providers to have them. But most schools barely touch on these topics. Health professionals and students in nursing, health administration, medicine, pharmacy, dentistry, policy, and other health professions can join. There are no applications, no admissions requirements, and no due dates.

Dallas, TX November 2–4, 2012 Quality and Safety Education for Nurses (QSEN) Program to increase knowledge, skills, and attitudes of nurses about quality and safety. The overall goal for the Quality and Safety Education for Nurses (QSEN) project is to meet the challenge of preparing future nurses who will have the knowledge, skills and attitudes (KSAs) necessary to continuously improve the quality and safety of the healthcare systems within which they work. Provide tools for faculty (staff development personnel) to teach these competencies.

Dallas, TX November 2–4, 2012 QSEN Competencies 1.Patient-centered care 2.Teamwork and collaboration 3.Evidence-based practice 4.Quality improvement 5.Safety 6.Informatics

Dallas, TX November 2–4, 2012 Wachter: –Modest improvement –Grade: B - Bielaszka-DuVernay: –Cites McGlynn et al (2003): US adults receive 55% of recommended care –Key issues – measuring improvement, incentives for better quality, disparities in care, patient involvement, health care complexity Nembhard et al.,: –Significant barriers to improvement: Many are organizational/cultural –Innovation implementation failures Has Health Care Improved?

Dallas, TX November 2–4, 2012 Infusion Safety: What can YOU do? Learn about patient safety and quality improvement (QI) Report potential and actual problems, concerns, errors Monitor your practice – processes and outcomes You job is not only to do your work, but to continuously improve your work (P. Batalden)

Dallas, TX November 2–4, 2012 Infusion Safety Med errors: account for 20% of medical injuries IV medications associated with 54% of potential adverse drug events –40% of deaths from adverse drug events due to wrong dose –16% deaths from adverse drug events due to wrong drug

Dallas, TX November 2–4, 2012 IV Infusion Safety Initiative Standardized medication delivery mechanism – identical IV smart pumps Decision-support drug library –Dose-error Reduction Software –Customized for different unit types –Provides alerts Capnography monitors for all patients on PCA Expanded role for RTs: rounds; first responders Wireless networking system – connectivity to pharmacy for monitoring, trending data Ongoing monitoring and analysis... and improvement Maddox, R. R., Danello, S., Williams, C. K., & Fields, M. (2008). Intravenous infusion safety initiative: Collaboration, evidence-based practices, and “smart” technology help avert high-risk adverse drug events and improve patient ouitcomes. In Advances in Patient Safety: New Directionsand Alternative Approaches. Vol 1-4, available at

Dallas, TX November 2–4, 2012 IV Infusion Safety Initiative Results Med errors averted: January-June 2006, 967 errors prevented, including 328 overdoses Decreased programming errors during PCA administration: 52 in first 4 months Cost savings: $2 million between Jan-Jun 2006 Improved nurse satisfaction with IV system Nurses felt more comfortable with aggressive pain management –St. Joseph’s/Candler Health System –Read more at AHRQ Innovations Exchange:

Dallas, TX November 2–4, 2012 Conclusion It is not enough for a nurse to be well- educated in the technical aspects of nursing and be well-intentioned in providing good care. Unless there are consistent efforts to measure and improve care, our health system will continue to provide great care in some places and situations, and mediocre or poor care in others. Nurses can make the difference.

Dallas, TX November 2–4, 2012 Questions?

Dallas, TX November 2–4, 2012 Agency for Healthcare Research & Quality, AHRQ Patient Safety Indicators (PSIs) – helpful in defining/standardizing measures: Centers for Medicare & Medicaid Services, Hospital Compare, Institute for Healthcare Improvement, Institute of Medicine, Institute for Safe Medical Practices, National Quality Forum, Quality and Safety Education for Nurses, The Joint Commission, US Pharmacopeia, Quality and Safety Resources

Dallas, TX November 2–4, 2012 Other Resources Bielaszka-DuVernay, C. (2011). Health policy brief. Improving quality and safety. Health Affairs. Institute of Medicine. (2001). Crossing the quality chasm. Report brief. Available at Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf Institute of Medicine. (1999). To err is human: Report brief. Available at Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf Nembhard, I. M., Alexander, J. A., Hoff, T. J., & Ramanujam, R. (2009). Why does quality of health care continue to lag? Insights from management research. Academy of Management Perspectives, 23(1), Wachter, R. (2010). Patient safety at ten: Unmistakable progress, troubling gaps. Health Affairs, 29(1),

Dallas, TX November 2–4, 2012 American Society for Quality Global community of people passionate about quality who use the tools and their ideas to make our world work better. The global voice of quality. AcademyHealth Seeks to improve health and health care by generating new knowledge and moving knowledge into action. Professional Organizations

Dallas, TX November 2–4, 2012 The Dartmouth Institute Dedicated to improving health care through education, research, policy reform, leadership improvement, and communication with patients and the public. Microsystem Academy The Place That Works: patients, families, and care teams. Professional Organizations

Dallas, TX November 2–4, 2012 Healthcare.gov: eports/quality a.html#na eports/quality a.html#na “ Take health care into your own hands.” Consumer- focused web site. Institute For Safe Medication Practices For Safe Medication Practices Devoted entirely to medication error prevention and safe medication use. Professional Organizations

Dallas, TX November 2–4, 2012 Institute for Healthcare Improvement: Focuses on motivating and building the will for change; identifying and testing new models of care in partnership with both patients and health care professionals; and ensuring the broadest possible adoption of best practices and effective innovations. Academy for Healthcare Improvement : Aim is to foster an interprofessional community that advances quality improvement in health care through scholarly and educational activities. Professional Organizations

Dallas, TX November 2–4, 2012 National Quality Forum: Promotes change through development and implementation of a national strategy for health care quality measurement and reporting. National Priorities Partnership Convened by the National Quality Forum, The National Priorities Partnership (NPP) offers consultative support to the Department of Health and Human Services on setting national priorities and goals for the HHS National Quality Strategy. The 48 member organizations also play a key role in identifying strategies for achieving the aims of better care, affordable care, and healthy people and communities; and facilitating coordinated, multi- stakeholder action. Professional Organizations

Dallas, TX November 2–4, %20August%202011%20Web(1).pdfhttp:// %20August%202011%20Web(1).pdf List of QI/Safety Journals

Dallas, TX November 2–4, 2012 The Joint Commission has a nice framework for conducting a Root Cause Analysis: Conducting_a_Root_Cause_Analysis_and_Acti on_Plan/ Conducting_a_Root_Cause_Analysis_and_Acti on_Plan/ Great example of RCA: Smetzer, J., Baker, C., Byrne, F. D., & Cohen, M. R. (2010). Shaping systems for better behavioral choices: Lessons learned from a fatal medication error. The Joint Commission Journal of Quality and Safety, 36(4), RCA

Dallas, TX November 2–4, 2012 For more information on FMEAs, go to analysis-tools/overview/fmea.html analysis-tools/overview/fmea.html Click on flowcharts or go to: analysis-tools/overview/flowchart.html analysis-tools/overview/flowchart.html FMEA