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Patient Safety Performance Improvement

Published byDouglas Carson Modified over 5 years ago

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Presentation on theme: "Patient Safety Performance Improvement"— Presentation transcript:

1 Patient Safety Performance Improvement
Clinical Orientation

2 Purpose To increase awareness that patient safety is a top organizational priority

3 Errors: High Risk Categories
Medication errors Surgical and invasive procedures Patient Identification Clinical equipment problems Unfortunately we cannot completely prevent errors but we can prevent errors from reaching the patient and causing harm. These are the highest risk categories here at Children’s.

4 What if an Error Happens?
Care for patient Disclosure of event to patient and family File Variance Report Care for staff involved in error Complete assessment of error Implement improvement actions If the error reached the patient and caused harm Care for the immediate needs of the pt Follow disclosure policy which includes: Contacting your immediate supervisor and the patients attending physician The patients physician and a trained hospital representative from administration will be there to assist Apology, investigation, designated contact for ongoing communication

5 Disclosure of Event Communicate known details of event to patient and family as soon as feasible. Planned approach Physician provides disclosure w/other staff in attendance House supervisor Hospital administration Spiritual Care Others as appropriate Establish plan for ongoing communication and follow up If the error reached the patient and caused harm Care for the immediate needs of the pt Follow disclosure policy which includes: Contacting your immediate supervisor and the patients attending physician The patients physician and a trained hospital representative from administration will be there to assist Apology, investigation, designated contact for ongoing communication

6 What if an Error Happens?
Care for patient Disclosure of event to patient and family File Variance Report Care for staff involved in error Complete assessment of error Implement improvement actions

7 Quantros Variance Reporting
Two types of computerized, web-based reports: Quantros Variance Reporting for variances involving patients, visitors, physicians, or students Actual and near miss events Quantros Feedback Manager for patient/parent complaints Refer to Quantros Variance learning module

8

9 To enter a variance Self guided training

10 Enter network user name and password

11 Variances: Report a Safety Event Complaints: Create a Feedback Ticket

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13

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15 Variance Classification: Outcome Scoring

16 Variance Report Routing Process
Automated, on-line routing to involved departments and Performance Improvement DO NOT copy a variance report DO NOT document in the patient record that a variance report was completed Several reports are based on variance data

17 Patient Care or Safety Concerns
Patients/families have the right to voice concerns or complaints without compromising patient care Information on how to report a concern in While You Are Here brochure given to patients/families on admission Written or verbal concerns not promptly resolved may meet grievance criteria and should be forwarded to the Compliance Officer

18 What if an Error Happens?
Care for patient Disclosure of event to patient and family File Variance Report Care for staff involved in error Complete assessment of error Implement improvement actions

19 Caregiver Support Caregivers are significantly affected by adverse events (“second victim”): Caused the error Dealing with after effects Trust of co-workers Debriefing sessions as needed after events Support available from managers, administration, and Employee Assistance Program (contact Employee Health)

20 What if an Error Happens?
Care for patient Disclosure of event to patient and family File Variance Report Care for staff involved in error Complete assessment of error Implement improvement actions If the error is a sentinel or SSE event PI will complete an investigation and poss RCA

21 Sentinel Event Description
A serious safety event that has resulted in an unanticipated death or major permanent loss of function not related to the natural course of the patient’s illness or underlying condition: Suicide of a patient Infant abduction Rape Hemolytic transfusion reaction Surgery on the wrong patient or body part

22 Sentinel Event Reporting Process
Immediately notify supervisor Complete a variance report Supervisor will notify on-call administrator; decision will be made regarding disclosure Administrator will arrange with Performance Improvement to complete a Root Cause Analysis RCA- Process to identify the basic causes and circumstances that resulted in a significant (sentinel) event This analysis is not designed to assign individual blame, but to improve/change a process Explain new RCA process

23 Root Cause Analysis Process to identify the basic
causes and circumstances that resulted in a significant (sentinel) event. This analysis is not designed to assign individual blame, but to improve/change a process.

24 Non-Sentinel Events Case Review
Staff closest to the error to help identify system improvement opportunities Administration and PI staff to help facilitate and make identified system improvements

25 What if an Error Happens?
Care for patient Disclosure of event to patient and family File Variance Report Care for staff involved in error Complete assessment of error Implement improvement actions

26 Performance Measurement
You can’t manage what you can’t measure.

27 Variances Over Time

28 Variances by Type

29

30 Lab Variance Report Action Highlights - 2015
PICU and 5MS moved specimen labels to bedside which reduced incidence of un-/mis-labeled; working to make this change housewide Housewide education on technique for screwing caps on specimen cups to prevent leakage; search for new/ improved specimen containers was not successful Enhanced order communication of Lab vs non-Lab collect 5 unlabeled specimens were considered “non-recollectable” and were processed after consultation with Pathology Medical Director EPIC Beaker (to be implemented August 2016) will Give Phlebotomists access to orders in real time, eliminating blood draw for recently cancelled tests and eliminating re-draw for recently ordered tests Further enhance communication of Lab vs non-Lab collection status Use bar code scanning across lab process Eliminate EPOC CSN vs MRN issues Reduce Lab pre-analytic specimen processing time, providing quicker result Provide positive patient identification, scanning both the armband and the specimen at bedside

31 Scorecards Q drive, Scorecard folder, Quality Scorecard file

32 Error Prevention Techniques

33 Do you act on your instincts or not?
Question….. Do you act on your instincts or not?

34 Be Mindful: Pay Close Attention
Vials similar to those confused during heparin events.

35 Advocate For Your Patient
Reasons we don’t speak up when we are uncomfortable about a situation Assumptions Fear Hierarchy Experience Culture Personality

36 Your Role You have a RESPONSIBILITY to notify your Chief Resident or a staff member when you identify unsafe patient situations.

37 Staff Input If you have an idea for a performance improvement project…… 1. Talk to your Chief Resident or 2. Call PI Mel Hall (PI Director ) x3813 Lia Whitehead (Sr Project Manager) x5127 Jill Jensen, (PI Specialist) x3843

38 Why? So that all children may have a better chance to live…

39 Post test 1 – Variance reports are used to identify system and process issues and provide opportunities for improvement across the organization. TRUE FALSE 2- Varience reportsare considered privileged and protected information (legally undiscoverable) under Nebraska Statute; HOWEVER, if the varience report itself is referenced in the medical record or if it is copied, this protection is lost. TRUE FALSE 3- If an error happens, which of the following should be done? a. Care for the patient b. Disclosure of event to patient family c. file varience report d. Care for staff involved in error e. Complete assessment of error f. Implement improvement of errors g. ALL of the above

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