1. Safety II in a large healthcare system
Safety II in Practice Workshop
Safety II in a large healthcare system
Rollin J. “Terry” Fairbanks MD, MS
Vice President, Quality & Safety, MedStar Health
Founding Director, National Center for Human Factors in Healthcare
Professor of Emergency Medicine, Georgetown University

2. Patient & Family Impact
The Safety I Approach
Proactive
Proactive
Reactive
Safety Event
Primary Prevention
Secondary Prevention
Tertiary Prevention
Realities of Actual Context
Design System for High Quality and Safety, Low Risk
Identify and Mitigate Existing Hazards
*Recover and Learn from Events
*Care for Patients & Family
Patient & Family Impact
We found literally hundreds of predictive events in our reporting system”
–Chief Pharmacy Officer, Clarion Health
Oppy here-
Finish thought on quality, then put stake in ground; then do safety quickly,  Oct/Nov we said– say, we need to move Maryland, now how do we do it
Big picture
Coming out of this with “I will statement”  review charts– don’t let this be an update make it a discussion
I should not say I know the answer– say I’ll lead– what I need from dev and exexution

3. The Safety I Approach #2 #1 #3 Consideration of Risk To: Patients
Severity of Damage #2 #1 #3
Consideration of Risk To:
Patients
Associates
Family & Visitors
Organization
(Weighs impact, risks, and cost)
Likelihood of Occurrence
Add quality information

4. The Safety I Approach Primary Prevention Secondary Prevention
Safety Event
Tertiary Prevention
Design System for High Quality and Safety, Low Risk
Identify and Mitigate Existing Hazards
(Safety Data Science)
Recover and Learn from Events
Event & Error Reports
Risk Mgt /Claims Data
Workers Comp
AHRQ SOPS
HCAPS
Open & Safe Discussion
Safety Huddle Notes
Peer Review, OPPE
Patient Complaints
SSE/Near Miss Reviews
Good Catch Program
EMR Analytics
Insurance/Risk org’s
Marketing Feedback
Pharmacy-Formulary/ID
NRC Picker comments
Google/Zocdoc/etc
Follow-Up Calls
Physician Satisfaction Surveys
People
Selection
Training (initial/ongoing)
Expectations/Guidelines
System/Technology/Process
Safety Culture
Clinical Excellence
Patient Satisfaction
Process Design
Standard Work
Device Selection
Built Design
Event Response
(CANDOR)
SUO--Early Notifications
Early Learning--Reviews
Care for Pt & Family
Optimize Care
Communication
Disclosure +/- apology
Bill Holds
Care for Caregiver
Impact Change/Learning
System-focused (PDCA)
People-focused
Learning
Learning
Learning
Learning

5. Analytics Action Insights
PSE Trends
Insights
Understand hazards
Pt Complaints
Prioritize response
Event Reviews
Qualitative Trending
Quantitative
Natural Language Processing
Human Factors Analysis
Data Visualization
Clinical Review
Systematize action
Risk Mgt Data
Action Team
Assign Task Team
Peer Review
IP Audits
Design Effective & Sustainable Solution
Huddle Data
Data Science & Analytics
Implement
Good Catch
SOP, SCS Surveys
Monitor now & later
Vizient
Also add: informart (claims data, demographics), new SSE Database: Integrate multiple databases, NLP solutions, ability to analyze freetext and unstructured and qualitative data, data visualizations.

6. The Safety II Approach
Ransomware Story
Cord Compression Story

7. The Safety II Approach
What is necessary to do Safety II in HC environment? (or, what will prohibit it?)
Leadership culture
Ability to adapt